1

POLICY BRIEF - PRE-PUBLICATION VERSION

TITLE: International migration of doctors and nurses to OECD countries: recent trends and policy

implications

AUTHORS: Dumont Ja, Lafortune Ga

AFFILIATION

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INTERNATIONAL MIGRATION OF DOCTORS AND NURSES TO OECD COUNTRIES:

RECENT TRENDS AND POLICY IMPLICATIONS

By Jean-Christophe Dumont (OECD) and Gaétan Lafortune (OECD)1

Table of contents2

Key messages

Introduction

1. Findings: Destination country perspective

1.1 Foreign-born health workers to OECD countries

1.2 Foreign-trained health workers to OECD countries

2. Findings: Sending country perspective

2.1 Countries of origin of migrant health workers in OECD countries

2.2 Expatriation rates from countries of origin

2.3 Impact of emigration on health systems in countries of origin

3. Impact of health and migration policies on international mobility of health workers

3.1 Impact of domestic education and training policies on international migrations

3.2 Impact of European Union enlargement on international mobility of health workers

3.3 Impact of the economic crisis and health spending reductions on the international migration

of health workers in Europe

3.4 Impact of bilateral agreements on the training and employment of health workers

Conclusions

Notes

References

1 The authors would like to thank Professor James Buchan (School of Health Sciences, Queen Margaret University) and

Ibadat S. Dhillon (Department for Health Workforce, World Health Organization) for their useful comments and suggestions

on a draft version. The opinion expressed and arguments employed here are the responsibility of the authors and do not

necessarily reflect those of the OECD or of its member countries. 2 The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such

data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West

Bank under the terms of international law.

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Key messages

This policy brief examines recent trends in the international migration of health workers to OECD

countries since 2000. It analyses these trends against the background of changes in migration and

health policies, as well as changing economic and institutional circumstances. In total, the number of

migrant doctors and nurses working in OECD countries has increased by 60% over that last decade.

This rate is higher for those emigrating to OECD countries from countries with severe health

workforce shortages, with an 84% increase over that same time period.

In a context when skilled migration is on the rise, immigrant doctors and nurses account for growing

shares of health professionals working in OECD countries. Foreign-born doctors accounted for 22% of

active doctors in OECD countries in 2010/11 (up from 20% in 2000/01), whereas foreign-born nurses

represented 14% of all nurses (up from 11% in 2000/01). The share of foreign-trained health workers

is lower (17% for doctors and 6% for nurses in 2012-14), suggesting that host countries provide some

of their training. The share of foreign-trained doctors and nurses in the two main destination countries

– the United States and the United Kingdom -- has decreased slightly since around 2006. India and

the Philippines account for the largest number of migrant doctors and nurses working in OECD

countries. Some countries, like the Philippines, have trained a large number of nurses who intend to

migrate. Some countries in Africa facing severe shortages of skilled health workers, such as Nigeria,

have seen the number of expatriates continue to grow over the past decade, nearly doubling.

These findings point towards three policy options:

1. By increasing their domestic education and training capacity to respond to current and future

projected demand, as well as promoting greater retention rates of currently active health

professionals, OECD countries can achieve greater self-sufficiency and reduce their reliance

on foreign-trained doctors and nurses.

2. At the same time, lower-income countries that are losing many of their skilled health workers

need to address some of the “push” factors and increase their efforts to try to retain them by

improving their working conditions and pay rates. These retention measures will require good

governance of the health system and long-term financial commitment, which in many cases

may require the support of the international community as called for by the WHO Global

Code of Practice on the International Recruitment of Health Personnel (‘WHO Global Code’).

3. In the spirit of the WHO Global Code, countries may also seek better ways to manage health

workforce migration by negotiating mutually beneficial agreements and assessing their

impact, and considerations might also be given to more ambitious approaches to global

governance building on the recent example in the area of climate change agreements.

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Introduction

The international migration of doctors, nurses and other health workers is not a new phenomenon, but

has drawn a lot of attention in recent years because of concerns that it exacerbates shortages of skilled

health workers in some countries, particularly in those countries that are already suffering from critical

shortages. The WHO Global Code of Practice on the International Recruitment of Health Personnel

(‘WHO Global Code’), was adopted by the World Health Assembly in 2010, to support improved

management of international health personnel migration according to globally accepted ethical norms

and standards. It encourages greater international cooperation and support in the area and encourages

countries to achieve greater “self-sufficiency” in the training of health workers, while also recognising

basic human right of freedom of movement (see Box 1).

Box 1. Excerpts from the WHO Global Code of Practice on the International Recruitment of Health

Personnel

Ethical international recruitment

The Code discourages the active recruitment of health workers from developing countries with critical workforce shortages.

Equal treatment of migrant health care workers

The Code highlights the importance of equal treatment of foreign-trained health workers and their locally-trained

counterparts. All health care workers should have the opportunity to assess the benefits and risks associated with employment

positions, and to make informed decisions about vacancies.

Health workforce development and sustainable health systems

Member States should develop strategies for workforce planning, training and retention, adapted to the specific

circumstances of each country, so that there is less of a need to recruit migrant health workers.

International cooperation

The Code encourages collaboration between health workers’ countries of origin and countries of destination, so that both

benefit from the migration of health professionals.

Technical collaboration and financial support

Developed countries should provide technical and financial assistance to developing countries experiencing a shortage of

health workers.

Data Gathering

Member States are encouraged to strengthen or establish health personnel information systems, including information on

health personnel migration, in order to collect, analyse and translate data into effective health workforce policies and plans.

Source: User’s Guide to the WHO Global Code of Practice on the International Recruitment of Health Personnel, WHO (2010).

The 2007 OECD study on “Immigrant Health Workers in OECD countries in the Broader Context of

Highly-Skilled Migration”, published in the International Migration Outlook, presented for the first

time a complete picture of the migration flows of health personnel to OECD countries by countries of

origin and destination (OECD, 2007). This work was recently updated in a chapter on “Changing

Patterns in the International Migration of Doctors and Nurses to OECD Countries”, published in the

2015 edition of the International Migration Outlook (OECD, 2015a). This policy brief presents some

of the main results from these chapters and additional information on health workforce policies from

the 2016 publication on Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right

Places (OECD, 2016) and the 2008 publication on The Looming Crisis in the Health Workforce. How

can OECD countries Respond? (OECD, 2008). It addresses the following questions:

What is the scale of the international migration of doctors and nurses to OECD countries, and

who heads where?

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What is the contribution of migrant health workers to their destination countries and what are

the consequences on their countries of origin?

How much do immigration and health policies affect migration grows and what is the scope of

bilateral agreements and new possible global governance arrangements to better manage

health workforce migration?

1. Findings: Destination country perspective

Immigration patterns can be measured based on nationality, place of birth or place of

education/training. The first approach, based on nationality, faces a number of shortcomings, with the

main one being that foreigners disappear from the statistics when they are naturalized. The second

approach, based on place of birth, is more meaningful because when the country of birth differs from

the country of residence, it implies that the person did cross the border at some point in time.

However, the main question that arises to evaluate the impact of highly skilled migration on origin

countries is where the education took place. Some foreign-born people arrived at younger ages, most

probably accompanying their family, while others came to the country to pursue tertiary education and

have stayed after completion of their study. In this context, most of the cost of education will have

been supported by the destination country, and/or by the migrants themselves, not by the country of

origin. The third approach, based on the place of education/training, is probably the most relevant

from a policy perspective, although it does raise a number of measurement issues related to the fact

that medical and nursing education and training can be very long and go through different stages that

may be occurring in both origin and destination countries (Dumont, Lafortune and Zurn, 2014).

This section uses two different datasets to monitor trends in the number of foreign-born

doctors and nurses working in OECD countries (based mainly on population-census data available in

many countries at 10 years intervals) and the number of foreign-trained doctors and nurses working in

OECD countries (based mainly on data from professional registries available each year).

It focusses only the migration of doctors and nurses given the preeminent role that these have

traditionally played in health service delivery in OECD countries.

1.1 Foreign-born health workers in OECD countries

Foreign-born doctors and nurses account for a significant and growing share of health

professionals in OECD countries. The share of foreign-born doctors increased in most countries

between 2000-01 and 2010-11 with the total number increasing from 19.5% to 22% across 23 OECD

countries, while the share of foreign-born nurses rose from 11% to 14.5% across 22 OECD countries.

In total, the number of migrant doctors and nurses working in OECD countries has increased by 60%

over that last decade. To a certain degree, the share of migrants among health professionals mirrors

that of highly-skilled immigrants in the workforce as a whole. However, the percentage of foreign-

born doctors tends to be greater than the percentage of immigrants among highly educated workers,

whereas the share of foreign-born nurses is similar or lower.

Although the United States receives the highest number of migrant doctors and nurses in absolute

terms, the steepest rises in foreign-born doctors between 2000-01 and 2010-11 were in the United

Kingdom and Germany. There were also significant increases in Ireland, Australia, New Zealand and

Switzerland, while numbers continued at their relatively high levels in Canada and the United States.

There were important variations across OECD countries in the proportion of health personnel

born abroad in 2010-11. For doctors, the share ranges from less than 3% in Poland and Turkey to over

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50% in Australia and New Zealand. The share of foreign-born nurses is insignificant in Poland and the

Slovak Republic, but over 30% in Switzerland, New Zealand, Australia and Luxembourg. In almost all

countries, with the exception of Turkey, Italy and Estonia, immigrants make up a higher proportion of

doctors than of nurses. This is particularly the case in Ireland, Australia and New Zealand.

Not surprisingly, the proportions of foreign-born doctors and nurses are highest in the main

settlement countries (e.g. Australia, Canada, Israel and New Zealand) and European countries like

Luxembourg and Switzerland. Other countries too – such as the United Kingdom and Belgium – also

near the top of the list in terms of the share of foreign-born health professionals, as do some Nordic

countries when it comes to doctors, and as does Ireland for both doctors and nurses.

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Table 1. Practising doctors by place of birth in 30 OECD countries, 2000/01 and 2010/11

Notes: Countries for which data for 2000/01 are derived from a census: AUS, AUT, CAN, CHE, ESP, FIN, FRA, GBR, HUN, IRL, LUX, MEX, NZL, POL, TUR, USA; countries for which data for 2000/01 are derived from LFS: BEL, DEU, NLD, NOR. Countries for which data for 2010/11 are derived from a census: AUS, CAN, CZE, DNK, ESP, EST, FIN, FRA, HUN, ISR, LUX, NLD, NOR, NZL, POL, PRT, SVK, SVN, USA; countries for which data for 2010/11 are derived from LFS: AUT, BEL, CHE, CZE, DEU, GBR, GRC, HUN, IRL, ITA, SWE, TUR. The percentage of foreign-born doctors whose place of birth is unknown are excluded from the calculation of the percentage of foreign-born doctors. Countries marked with an asterisk (*) are not counted in the total (OECD23) due to data gaps at least for one year.

1. Other sources indicate a slightly higher increase in the number of doctors in Belgium during this period.

2. Some doctors undergoing specialty training may not be counted in 2011.

3. In 2001, doctors are only partially covered.

4. Other sources indicate a slightly lower increase in the number of doctors in Sweden during this period.

5. Some doctors undergoing specialty training may not be counted in 2000.

Source: OECD (2007) for 2000/01 data, DIOC 2010/11 and LFS 2009/12 for 2010/2011 data.

Country of residence TotalForeign-

born

% foreign-

born Total

Foreign-

born

% foreign-

born

Australia (2001) 48 211 20 452 42.9 68 795 36 076 52.8 (2011)

Austria (2001) 30 068 4 400 14.6 40 559 6 844 16.9 (2011/12)

Belgium1

(1998-02) 39 133 4 629 11.8 40 148 10 202 25.4 (2011/12)

Canada (2001) 65 110 22 860 35.1 79 585 27 780 34.9 (2011)

Czech Republic* … … … 39 562 3 468 8.8 (2011)

Denmark2

(2002) 14 977 1 629 10.9 15 403 2 935 19.1 (2011)

Estonia* … … … 4 145 747 18.0 (2011)

Finland (2000) 14 560 575 4.0 18 937 1 454 7.7 (2011)

France (1999) 200 358 33 879 16.9 224 998 43 955 19.5 (2011)

Germany (1998-02) 282 124 28 494 11.1 366 700 57 210 15.7 (2011/12)

Greece3

(2001) 13 744 1 181 8.6 49 577 3 624 7.3 (2011/12)

Hungary (2001) 24 671 2 724 11.0 28 522 3 790 13.3 (2011)

Ireland (2002) 8 208 2 895 35.3 12 832 5 973 46.6 (2011/12)

Israel* … … … 23 398 11 519 49.2 (2011)

Italy* … … … 234 323 11 822 5.0 (2011/12)

Luxembourg (2001) 882 266 30.2 1 347 536 40.0 (2011)

Mexico* (2000) 205 571 3 005 1.5 … … …

Netherlands (1998-02) 42 313 7 032 16.7 57 976 8 429 14.6 (2011)

New-Zealand (2001) 9 009 4 215 46.9 12 708 6 897 54.3 (2011)

Norway (1998-02) 12 761 2 117 16.6 19 624 4 460 22.7 (2011)

Poland (2002) 99 687 3 144 3.2 109 652 2 935 2.7 (2011)

Portugal (2001) 23 131 4 552 19.7 36 831 6 040 16.4 (2011)

Slovak Republic* … … … 21 552 823 3.8 (2011)

Slovenia* … … … 5 556 1 006 18.1 (2011)

Spain (2001) 126 248 9 433 7.5 210 500 21 005 10.3 (2011)

Sweden4

(2003) 26 983 6 148 22.9 47 778 14 173 29.8 (2011/12)

Switzerland5

(2000) 23 039 6 431 28.1 43 416 18 082 41.6 (2011/12)

Turkey (2000) 82 221 5 090 6.2 104 950 3 003 2.9 (2011/12)

United Kingdom (2001) 147 677 49 780 33.7 236 862 83 951 35.4 (2011/12)

United States (2000) 807 844 196 815 24.4 838 933 221 393 26.4 (2007-11)

OECD Total (23 countries) 2 142 959 418 741 19.5 2 666 632 590 748 22.2

Doctors

2000/01 2010/11

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Table 2. Practising nurses by place of birth in 30 OECD countries, 2000/01 and 2010/11

Notes: Countries for which data for 2000/01 are derived from a census : AUS, AUT, CAN, CHE, ESP, FIN, FRA, GBR, HUN, IRL, LUX, MEX, NZL, POL, PRT, TUR, USA ; countries for which data for 2000/01 are derived from LFS: BEL, DEU, NLD, NOR ; countries for which data for 2000/01 are derived from a register : DNK. Countries for which data for 2010/11 are derived from a census: AUS, CAN, ISR, NZL, USA; countries for which data for 2010/11 are derived from LFS : AUT, BEL, CHE, CZE, DEU, DNK, ESP, EST, FIN, FRA, GBR, GRC, HUN, IRL, ITA, LUX, NLD, NOR, POL, PRT, SVK, SVN, SWE, TUR. Foreign-born nurses whose place of birth is unknown are excluded from the calculation of the percentage of foreign-born nurses. Countries marked with an asterisk (*) are not counted in the total (OECD23) due to data gaps for at least one year.

1. Other sources indicate that the number of nurses in Denmark may be about 25% higher in 2002 and in 2012. Some associate professional nurses may not be counted.

2. Other sources indicate that the number of nurses in Switzerland may be about 50% higher in 2000 and 20% higher in 2010.

Source: OECD (2007) for 2000/01 data, DIOC 2010/11 and LFS 2009/12 for 2010/2011 data.

Country of residence TotalForeign-

born

% foreign-

born Total

Foreign-

born

% foreign-

born

Australia (2001) 191 105 46 750 24.8 238 935 78 508 33.2 (2011)

Austria (2001) 56 797 8 217 14.5 70 147 10 265 14.6 (2009-10)

Belgium (1998-02) 127 384 8 409 6.6 140 054 23 575 16.8 (2011-12)

Canada (2001) 284 945 48 880 17.2 326 700 73 425 22.5 (2011)

Czech Republic* … … … 89 301 1 462 1.6 (2011-12)

Denmark1

(2002) 57 047 2 320 4.1 61 082 6 301 10.3 (2011-12)

Estonia* … … … 8 302 2 162 26.0 (2011-12)

Finland (2000) 56 365 470 0.8 72 836 1 732 2.4 (2011-12)

France (1999) 421 602 23 308 5.5 550 163 32 345 5.9 (2009-10)

Germany (1998-02) 781 300 74 990 10.4 1 074 523 150 060 14.0 (2009-12)

Greece (2001) 39 952 3 883 9.7 55 364 1 919 3.5 (2011-12)

Hungary (2001) 49 738 1 538 3.1 59 300 1 218 2.1 (2011-12)

Ireland (2002) 43 320 6 204 14.3 58 092 15 606 26.9 (2011-12)

Israel* … … … 31 708 16 043 50.6 (2011)

Italy* … … … 399 777 39 231 9.8 (2011-12)

Luxembourg (2001) 2 551 658 25.8 4 372 1 347 30.8 (2011-12)

Mexico* (2000) 267 537 550 0.2 … … …

Netherlands (1998-02) 259 569 17 780 6.9 323 420 30 909 9.6 (2009-10)

New Zealand (2001) 33 261 7 698 23.2 40 002 13 884 35.0 (2011)

Norway (1998-02) 70 698 4 281 6.1 97 725 8 795 9.0 (2009-10)

Poland (2002) 243 225 1 074 0.4 245 667 595 0.2 (2009-10)

Portugal (2001) 36 595 5 077 13.9 53 491 4 643 8.7 (2011-12)

Slovak Republic* … … … 52 773 303 0.6 (2011-12)

Slovenia* … … … 17 124 1 483 8.7 (2011-12)

Spain (2001) 167 498 5 638 3.4 252 804 14 400 5.7 (2011-12)

Sweden (2003) 98 505 8 710 8.9 113 956 15 834 13.9 (2011-12)

Switzerland2

(2000) 62 194 17 636 28.6 110 069 36 531 33.3 (2011-12)

Turkey* (2000) … … … 147 611 4 484 3.1 (2009-10)

United Kingdom (2001) 538 647 81 623 15.2 618 659 134 075 21.7 (2011-12)

United States (2000) 2 818 735 336 183 11.9 3 847 068 561 232 14.6 (2007-11)

OECD Total (22 countries) 6 441 033 711 327 11.0 8 414 429 1 217 200 14.5

2000/01 2010/11

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1.2 Foreign-trained health workers in OECD countries

In most OECD countries, the proportion of health workers trained abroad is lower than that of

health workers born abroad, indicating that host countries provide part of migrants’ education and

training.

In 2012-2014, foreign-trained doctors accounted for 17% of all doctors across 26 OECD

countries, and foreign-trained nurses for 6% of all nurses across 25 countries. While the number of

foreign-trained health workers are usually lower than the foreign-born, in some countries (e.g. Israel),

the share of foreign-trained health workers is higher, reflecting the fact that many people born in the

country have gone to study abroad before returning back to practice in their home country.

Israel, New Zealand, Norway, Ireland and Australia have the highest share of foreign-trained

doctors, with more than 30% of doctors trained abroad. Following these countries are the United

Kingdom, Switzerland, the United States, Canada and Sweden, with rates between 24% and 30%. The

very high proportion of foreign-trained doctors in Israel reflects not only the importance of

immigration in this country, but also the fact that an increasing number of new licenses are issued to

people born in Israel but trained abroad (about one-third in 2014). Similarly, in Norway, large

numbers of Norwegians study medicine abroad, with the vast majority of them returning to practice in

Norway.

In absolute numbers, the United States has by far the highest number of foreign-trained health

workers, with more than 200 000 doctors trained abroad in 2013 and almost 250 000 nurses.

Following the United States is the United Kingdom (with more than 48 000 foreign-trained doctors

and 86 000 foreign-trained nurses in 2014), and Germany (with nearly 29 000 foreign doctors in 2014

and 70 000 foreign nurses in 2010, latest year available).

In most OECD countries, the proportion of nurses trained abroad tends to be much lower than

that of doctors. Only Switzerland, New Zealand, Australia and Israel report figures higher than 10% in

2012-14. Recent trends in the migration of foreign-trained nurses also vary across countries. There has

been a strong rise in the immigration of foreign-trained nurses in Italy, primarily driven by the arrival

of nurses trained in Romania. However, in some other countries (e.g., the Netherlands, Portugal and

the United Kingdom), there has been a reduction in the number and proportion of foreign-trained

nurses between 2006 and 2012-2014.

Most OECD countries have stepped up their education and training efforts of doctors and nurses

since 2000 in response to expected shortages in the context of population ageing generally (which is

expected to increase the demand for health services) and the ageing of the medical and nursing

workforce (which is expected to reduce their supply). These efforts have partly slowed down the

increase in international recruitment (see the section below on the impact of domestic education and

training policies on migration flows).

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Table 3. Foreign-trained doctors working in 26 OECD countries, 2000, 2006 and 2012-14

Note: Doctors whose place of training is unknown have been excluded from the calculation of the percentage of foreign-trained doctors (Netherlands, Slovak Republic, Slovenia and United Kingdom).

1. The data refer to foreign citizens (not necessarily foreign-trained).

2. Data cover England, Wales and Scotland (but not Northern Ireland).

3. The percentage in 2000 is calculated based on all doctors registered to practise. Data for 2006 and 2013 refer to doctors who are professionally active.

e: estimation.

Source: See Annex 4.A1 in chapter 4 of OECD (2016), Health Workforce Policies in OECD countries: Right Jobs, right Skills, Right Places.

Country of

residenceYear Total

Foreign-

trained% of total Year Total

Foreign-

trained% of total Year Total

Foreign-

trained% of total

Australia 2000 ... ... ... 2005 ... ... 25.0% 2013 82 498 25 153 30.5%

Austria 2000 25 611e 461 1.8% 2006 30 236 888 2.9% 2014 35 844 1 640 4.6%

Belgium 2000 44 380 1 934 4.4% 2006 49 695 2 636 5.3% 2014 59 070 6 732 11.4%

Canada 2000 64 462 13 701 21.3% 2006 70 870 15 237 21.5% 2013 90 205 21 225 23.5%

Chile 2000 ... ... ... 2006 ... ... ... 2014 36 013 5 489 15.2%

Czech Republic 2000 43 765 579 1.3% 2006 44 064 1 744 4.0% 2014 41 671 1 135 2.7%

Denmark 2000 15 551 681 4.4% 2006 18 403 1 145 6.2% 2012 20 250 1 127 5.6%

Estonia 2002 2 259 0 0.0% 2006 5 336 30 0.6% 2014 6 294 166 2.6%

Finland 2000 ... ... ... 2005 ... ... ... 2012 20 866 4 154 19.9%

France 2000 199 445 7 795 3.9% 2006 212 711 12 261 5.8% 2013 219 833 20 275 9.2%

Germany12000 267 965 9 971 3.7% 2006 284 427 14 703 5.2% 2013 326 945 28 901 8.8%

Hungary 2000 ... ... ... 2006 37 908 2 917 7.7% 2013 32 668 2 470 7.6%

Ireland 2000 12 243e 1 359 11.1% 2006 15 512e 4 663 30.1% 2014 19 066 6 877 36.1%

Israel 2000 21 869 14 080 64.4% 2006 23 890 14 746 61.7% 2014 25 570 14 839 58.0%

Netherlands 2001 39 772 706 1.8% 2006 45 051 941 2.1% 2011 51 939 1 352 2.6%

New Zealand 2000 9 890 3 756 38.0% 2006 11 889 4 833 40.7% 2014 14 786 6 298 42.6%

Norw ay 2000 ... ... ... 2008 18 557 5 996 32.3% 2014 22 659 8 447 37.3%

Poland 2000 ... ... ... 2008 119 604 2 529 2.1% 2012 125 073 2 203 1.8%

Slovak Republic 2000 18 571e 130 0.7% 2004 17 375e 139 0.8% 2011 16 899 506 3.0%

Slovenia 2000 ... ... ... 2006 ... ... ... 2013 5 416 781 14.4%

Spain 2000 ... ... ... 2006 ... ... ... 2011 207 042 19 462 9.4%

Sw eden 2000 27 502 3 827 13.9% 2006 32 802 6 321 19.3% 2012 38 144 9 283 24.3%

Sw itzerland 2000 25 272e 2 982 11.8% 2008 29 653 6 479 21.8% 2012 31 858 8 617 27.0%

Turkey 2000 85 242 55 0.1% 2006 104 475 240 0.2% 2013 133 775 261 0.2%

United Kingdom22000 ... ... ... 2008 146 834 43 885 29.9% 2014 172 561 48 766 28.3%

United States32000 ... ... 25.5% 2006 664 814 166 810 25.1% 2013 859 470 214 438 25.0%

2 696 415 460 597 17.1%

2000 2006 2012-2014

OECD Total (26 countries)

11

Table 4. Foreign-trained nurses working in 25 OECD countries, 2000, 2006 and 2012-14

Note: Nurses whose place of training is unknown are excluded from the calculation of the percentage of foreign-trained nurses (e.g. Switzerland).

1. The data only include professional nurses (and exclude associate professional nurses).

2. The data refer only to general nurses.

3. The data refer to citizens born abroad, not German by birth (except ethnic German repatriates) and the highest degree in nursing acquired in a foreign country.

4. Different source in 2001 (Aiken et al., 2004).

5. Data refer to all nurses registered to practice.

e: estimation.

Source: See Annex 4.A1 in chapter 4 of OECD (2016), Health Workforce Policies in OECD countries: Right Jobs, right Skills, Right Places.

Country of

residenceYear Total

Foreign-

trained% of total Year Total

Foreign-

trained% of total Year Total

Foreign-

trained% of total

Australia 2000 ... ... ... 2007 263 332 38 108 14.5% 2013 296 029 47 507 16.0%

Belgium 2000 130 560 679 0.5% 2006 150 817 1 290 0.9% 2014 186 278 5 411 2.9%

Canada 2000 232 566 14 187 6.1% 2006 326 170 21 445 6.6% 2013 375 768 28 330 7.5%

Chile 2000 ... ... ... 2006 ... ... ... 2014 34 674 702 2.0%

Denmark12000 49 694 889 1.8% 2006 51 840 818 1.6% 2012 55 037 724 1.3%

Estonia 2000 ... ... ... 2006 10 264 ... ... 2014 12 519 4 0.0%

Finland22000 ... ... 0.2% 2005 ... ... 0.3% 2012 72 471 1 293 1.8%

France 2000 404 564 7 016 1.7% 2006 493 503 11 712 2.4% 2014 622 052 17 692 2.8%

Germany32000 ... ... ... 2006 ... ... ... 2010 1 211 000 70 000 5.8%

Hungary 2000 ... ... ... 2006 ... ... ... 2013 53 323 650 1.2%

Ireland 2000 … ... ... 2004 60 819e 8 758 14.4% 2013 ... ... ...

Israel 2000 39 064 7 277 18.6% 2006 43 481 6 077 14.0% 2014 45 982 4 528 9.8%

Italy 2000 304 159 1 825 0.6% 2006 358 746 15 108 4.2% 2014 424 813 20 072 4.7%

Netherlands 2001 169 580 1 495 0.9% 2006 186 990 2 149 1.1% 2011 198 694 1 358 0.7%

New Zealand 2002 33 027 4 860 14.7% 2008 39 247 8 931 22.8% 2014 45 572 11 170 24.5%

Norw ay 2000 ... ... ... 2008 70 575 5 022 7.1% 2014 83 647 7 640 9.1%

Poland 2000 ... ... ... 2008 268 015 5 0.0% 2012 278 496 7 0.0%

Portugal 2002 41 902 1 954 4.7% 2006 51 095 2 285 4.5% 2013 65 868 1 947 3.0%

Slovenia 2000 ... ... ... 2006 ... ... ... 2013 4 797 20 0.4%

Spain 2000 ... ... ... 2006 ... ... ... 2011 250 277 5 247 2.1%

Sw eden 2000 88 302 2 358 2.7% 2006 98 905 2 789 2.8% 2012 106 176 2 882 2.7%

Sw itzerland 2000 ... ... ... 2006 ... ... ... 2012 61 609 11 536 18.7%

Turkey 2000 69 550 11 0.0% 2006 82 626 79 0.1% 2013 139 544 239 0.2%

United Kingdom42001 632 050e 50 564 8.0% 2006 659 470 88 609 13.4% 2014 683 625 86 668 12.7%

United States52000 ... ... ... 2006 ... ... ... 2012 4 104 854e 246 291e 6.0%

9 413 105 571 918 6.1%

2000 2006 2012-2014

OECD Total (25 countries)

12

2. Findings: Sending country experience

2.1 Countries of origin of migrant health workers in OECD countries

The emigration of health workers from their country of origin can be reconstructed through the

use of data collected in OECD destination countries.3 Figure 1 presents the distribution by region of

origin of foreign-born doctors and nurses who were working in OECD countries in 2000/01 and

2010/11.

In 2010/11, 26% of doctors and 29% of nurses working in an OECD country were coming from

other OECD countries. These figures reflect both the scale of historical migration – particularly of

Europeans to the main settlement countries – and the vitality of intra-EEA, trans-Tasman, and North

American flows. Moving beyond intra-OECD countries movements, the region from which most

doctors originated was South-East Asia, while most nurses came from the Western Pacific region.

Growth in the number of expatriate doctors between 2000/01 and 2010/11 was distributed fairly

evenly among these different regions. For nurses, it was more uneven, depending on the region of

origin.

Figure 1. Foreign-born doctors and nurses in 30 OECD countries by main region of origin, 2000/01 and 2010/11

Note: The regional groupings correspond to the 6 WHO regions (for country details, see http://www.who.int/about/regions), except the OECD countries.

Source: Includes countries where 2000/01 and 2010/11 data are available (see Table 1), except Germany.

Figure 2 shows the top 25 countries of origin of foreign-born doctors and nurses working in

OECD countries in 2010/11 and the increase since 2000/01. In the South-East Asia region, the

increase came mainly from doctors born in India. Germany and the United Kingdom were the main

countries of origin among OECD countries. In non-OECD European countries, Romania also stands

out for its high volume of emigration. In the Eastern Mediterranean and the Western Pacific regions,

Pakistan and China accounted for the highest shares of foreign-born doctors working in OECD

countries, while the Philippines sent the largest proportion of nurses. In the Africa region, immigrant

3 These data provide a lower bound estimate as they do not include migration to other non-OECD countries.

136 344

103 290

76 80066 168

55 541 50 092 44 384

0

50 000

100 000

150 000

200 000

250 000

300 000

350 000

2000/01 2010/11

309 028

88 599

35 023

281 296

135 970

155 430

58 657

2000/01 2010/11

Doctors Nurses

13

doctors in OECD countries came primarily from Nigeria and South Africa, and in the Americas, from

Colombia and Peru, while the Caribbean supplied the most nurses.

India and the Philippines account for the largest shares of migrant doctors and nurses in OECD

countries. They were already the two main sending countries in 2000/01, but their outflows have

further grown over the past decade. The first seven countries of origin accounted for nearly half of the

increase in the number of foreign-born doctors. For nurses, nearly half of those emigrating came from

the first four countries of origin. The tendency of some countries to training health professionals who

intend to migrate is an important factor in the international mobility of health workers.

Figure 2. Foreign-born doctors and nurses in OECD countries by 25 main countries of origin, 2000/01 and 2010/11

Source: Includes countries where 2000/01 and 2010/11 data are available (see Tables 1 and 2), except Germany.

2.2 Expatriation rates from countries of origin

Table 5 summarises the broad trends concerning expatriation rates over the past decade.4

Between 2000/01 and 2010/11, emigration rates have risen for both doctors and nurses. In 2010/11,

about 6% of doctors and nurses in the world had migrated to an OECD country.

4 Table 3.A1.1 in the International Migration Outlook 2015 presents expatriation rates by country of origin.

0 5 000 10 000 15 000 20 000 25 000 30 000

Italy

Cuba

Russian Federation

Lebanon

Morocco

United States

Syria

Colombia

Malaysia

Nigeria

Poland

Egypt

Korea

Viet Nam

South Africa

Canada

Romania

Algeria

Iran

Philippines

Pakistan

United Kingdom

Germany

China

India

2010/11 2000/01Doctors

0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000

Iran

Kenya

Cuba

Trinidad and Tobago

Guyana

New Zealand

Romania

South Africa

Ghana

Viet Nam

Zimbabwe

France

Ireland

Poland

Korea

Mexico

China

Haïti

Nigeria

Canada

Jamaica

Germany

United Kingdom

India

Philippines

2010/11 2000/01Nurses

86 680 (2010/11) and 55 794 (2000/01) 221 344 (2010/11) and 110 774 (2000/01)

// //

14

Table 5. Trends in the expatriation rates of doctors and nurses to OECD countries, 2000/01 and 2010/11

Notes: The average expatriation rate corresponds to the unweighted average of each country's expatriation rate (and therefore does not take into account the demographic weight of each country) whereas the overall expatriation rate indicates the share of expatriates in OECD countries in the total number of doctors and nurses of the countries examined. The average expatriation rate is higher than the global rate, because countries with the lowest populations and those that are islands show the highest rates of emigration. Countries for which expatriates are under 10 for nurses (5 for doctors) or resident in the origin country are below 50 for nurses (10 for doctors) are not included in the calculations. Expatriation rates are only calculated for countries for which data back to 2005 at the latest are available. 149 countries of origin are therefore included for doctors and 141 for nurses. Data on the expatriation rates in 2000/01 of nurses born in Brazil, India and South Africa have been updated on the basis of new data on the number of nurses working in these countries in 2000/01. The revised expatriation rates in 2000/01 are: Brazil: 1.5%, India: 2.9% and South Africa: 12.6%.

Source: OECD (2007); DIOC 2010/11, LFS 2009/12 and Global Health Observatory (WHO).

In Africa, the expatriation rate for nurses in South Africa rose from 12.6% in 2000/01 to 16.5% in

2010/11, in Nigeria from 10% to 17%, and in Zimbabwe from 28% to 43%. For the two main origin

countries of doctors in Africa who have migrated to an OECD country (South Africa and Nigeria),

expatriation rates have also risen:- in South Africa (from 17% to 22%), and a lower rise in in Nigeria

(from 11.7% to 12.3%). In some cases, the changes observed in the expatriation rates are not so much

related to an increase or a decrease in migration flows, but rather with a change in the national ‘stock’

of health workers. For example, the expatriation rate for doctors in Angola dropped from 63% to 34%,

while the number of expatriate doctors remained stable. This reflects a sharp increase in the number of

doctors registered by the WHO as working in Angola over the last decade. For Nigeria, the number of

expatriate doctors nearly doubled in ten years (from around 4 600 to 8 200), whereas the expatriation

rate remained stable at around 12%. This again reflects the growth in the number of doctors working

in the country. On the other hand, the increase in the expatriation rate of doctors in Zimbabwe (from

28% to 56%) is in large part attributable to the fact that the number of doctors practising in the country

fell by more than half.

Despite the sharp increase in the number of health professionals emigrating from India and the

Philippines, their expatriation rates remained relatively constant. For example, the number of

expatriate Indian doctors jumped from 56 000 in 2000/01 to around 87 000 in 2010/11, but the

corresponding expatriation rates rose only by one-half of a percentage point to 8.6%. In China, the

number of expatriate nurses doubled in ten years (from around 12 200 to 24 400), but the expatriation

rate remained at only 1%.

2.3 Impact of emigration on health systems in countries of origin

In its 2006 World Health Report, WHO estimated that 2.4 million health workers were needed in

the 57 countries considered to be suffering from critical shortages.5 In 2010/11, WHO estimated that

5 Countries with critical shortages were defined in the World Health Report 2006 as those with less than

22.8 health professionals (doctors, nurses and midwives) per 10 000 people and where less than 80%

of childbirths were delivered by skilled birth attendants.

2000/01 2010/11 2000/01 2010/11

Overall expatriation rate 5.3 5.9 4.5 5.7

Average expatriation rate 19.5 21.8 16.6 21.8

Median expatriation rate 13.0 13.6 6.4 10.4

Doctors Nurses

15

54 countries were still facing critical shortages of about 2 million health workers. Most of these

countries (31 countries) were in Africa. Progress made in India to close the gap between health worker

supply and demand accounted for much of the reduced shortage in 2010/11. In Africa and the

Americas, however, the gap widened (WHO, 2013). It should be noted that WHO no longer uses the

categorization of countries with critical shortages.

Table 7 assesses the relative contribution of emigration for those countries where the density of

health workers was considered too low and to what extent such emigration contributed to these critical

shortages. It presents data at a broad WHO region level; it is important to keep in mind that the actual

impact in different countries can vary significantly.

Table 7. Estimated critical shortages of doctors, nurses and midwives, by WHO region, 2000/01 & 2010/11

Note: WHO no longer uses the categorization of countries with critical shortages

Source: OECD (2007), DIOC 2010/11 and LFS 2009/12, Global Health Observatory (WHO).

The slightly smaller group of countries suffering from critical shortages have seen their health

workers continue to emigrate in growing numbers between 2000/01 and 2010/11. Emigration therefore

appears to have contributed to these critical shortages over the past decade. It accounted for 20% of

estimated critical shortages in 2010/11, compared with 9% in 2000/01. In the decade preceding the

adoption of the WHO Global Code, the number of doctors and nurses originating from countries with

severe shortages who emigrated to OECD countries grew by 84%, while the total number of migrant

health workers increased by 60%.

In African countries assessed as facing critical shortages, the number of health professionals born

in these countries working in OECD countries doubled between 2000/01 and 2010/11. At the same

time, the critical shortages in their origin countries grew, so the migration’s share of the estimated

shortage rose from 7% in 2000/01 to 13% in 2010/11. However, the picture varies from one country to

another. Ethiopia was the African country with the most severe critical shortage. There was an

estimated shortfall of 175 000 health workers in 2010/11, but only 6 000 doctors and nurses had

emigrated. In Nigeria, by contrast, emigrant workers accounted for over 40% of the critical shortage,

with 36 000 expatriates for a shortfall estimated at 81 000 health workers.

In the Americas, the high share of the estimated shortage attributed to migrant health personnel is

due mainly to the high emigration of nurses from the Caribbean. In absolute terms, the greatest

shortage is in the South-East Asia region. Shortages are particularly acute in Bangladesh and

Indonesia, with health worker shortfalls estimated at 260 000 and 240 000 respectively. In the Eastern

Mediterranean region, the increase in emigration – particularly of Pakistan-born doctors – to the

Total

2000/01 2010/11 2000/01 2010/11 2000/01 2010/11 2000/01 2010/11 2000/01 2010/11

Africa 46 36 31 464 865 579 748 817 992 941 505 61 212 124 824 7% 13%

Americas 35 5 5 82 647 59 695 37 886 49 376 26 917 36 689 71% 74%

South-East Asia 11 6 7 1 763 637 2 318 101 1 164 001 661 267 90 216 177 018 8% 27%

Europe 52 0 0 … … … … … … … …

Eastern Mediterranean 21 7 6 278 412 344 050 306 031 263 394 29 926 45 703 10% 17%

Western Pacific 27 3 5 20 991 26 443 32 560 38 269 3 577 5 732 11% 15%

Total number of countries with

critical shortages57 54 2 610 552 3 328 037 2 358 470 1 953 810 211 848 389 966 9% 20%

Sources: OECD (2007), DIOC 2010/11 and LFS 2009/12, Global Health Observatory (WHO).

WHO region

Number of countries In countries with critical shortagesForeign-born doctors and nurses in OECD countries by

region of origin

With critical shortages Total stock Estimated critical shortage NumberPercentage of the estimated

critical shortage

16

OECD area accounted for 17% of the region’s estimated critical shortage in 2010/11, up from 10% in

2000/01. Cambodia, Laos, and Papua New Guinea are the countries where the shortfalls in health

personnel are the greatest in the Western Pacific region. In this region, migration also accounted for a

higher share of the shortage in 2010/11 compared with 2000/01.

There are many possible causes behind the international migration of health workers and

consequences for the health system of origin countries. On one hand, this migration may be interpreted

as a symptom rather than a determinant of the problems facing these health systems. The fact that

there is a shortage does not necessarily mean that there is a lack of health workers with the required

qualifications and skills: it may also reflect the reluctance of these people to work under existing

conditions (Buchan and Aiken, 2008). On the other hand, the emigration of health workers can indeed

be a problem when the volume of outflows is significant, particularly when it concerns skills that are

in short supply or when migrants come from regions that are already undersupplied (Wismar et al.,

2011). The emigration of even a limited number of specialists can have an important impact on the

delivery of health care, especially in rural areas where there is a dearth of health workers (Eke et al.,

2011; Galan et al., 2011).6

3. Impact of health and immigration policies on international mobility of health workers

The growing international mobility of health professionals must be viewed in relation to other

elements that also affect the supply of health workers, primarily the entry on the labour market of new

graduates on the inflow side, and the retirement or exit of certain workers on the outflow side. The

main factors influencing inflows and outflows are education and training policies, immigration

policies, and changes in economic and institutional circumstances.

3.1 Impact of domestic education and training policies on international migration

Policies relating to the education and training of doctors, nurses and other health professionals are

among the most powerful tools that countries can use to adjust the supply to projected needs. Training

sufficiently large numbers of health workers to curb any dependence on immigration is in fact one of

the key principles of the WHO Global Code of Practice. Most OECD countries control in some ways

the number of students admitted to medical and nursing schools, mainly through numerus clausus

policies, and several countries have raised admission levels in these programmes since 2000, either to

meet expected growing needs for health services or to reduce their dependence on foreign-trained

doctors or nurses.

The efforts to train new doctors have intensified in most OECD countries since 2000, including in

the United Kingdom, Australia, Canada and to a lesser extent the United States. The number of

students admitted and graduating from nursing programmes also rose sharply in many countries since

2000.7

The United States provides a striking example of how a substantial increase in domestic training

efforts for nurses have reduced the need to recruit foreign-trained nurses. Between 2001 and 2012, the

number of domestically-trained nurses passing the certification exam more than doubled, rising from

6 Remittances is also often mentioned as a benefit of emigration that might be increased. The International

Monetary Fund recently suggested that reducing remittance costs could increase the net revenues that

private households receive in source countries (IMF, 2015).

7 See, for example, Figures 3.18 and 3.19 in the International Migration Outlook 2015 and Figures 5.7 and 5.16

in Health at a Glance 2015).

17

less than 70 000 in 2001 to nearly 150 000 in 2012 (Figure 3, right panel). This was accompanied by a

sharp drop in the number of foreign-trained nurses who passed that exam, coming down from a peak

of around 23 000 in 2007 to only about 5 000 in 2012. For doctors, up until now, the number of newly-

registered doctors who got their initial degree in another country has remained more stable but if the

number of domestically-trained doctors continues to go up, it is possible that fewer foreign-trained

doctors will become registered in the United States in the coming years (Figure 3, left panel).

Figure 3. Changes in the number of domestic graduates and inflow of foreign-trained health workers, United States, 2001-13

Doctors Nurses

Source: The US Nursing Workforce: Trends in Supply and Education, Health Resources, Services Administration (HRSA), 2013; American Medical Associations, National Centre for Health Statistics.

In the United Kingdom, the steady rise in the number of domestic medical graduates since 2002

has also reduced the need to recruit abroad (Figure 4), although the annual inflow of foreign-trained

doctors seems to have stabilised in recent years. But the countries of origin of foreign-trained doctors

in the United Kingdom has changed considerably over the past decade, with a growing proportion of

doctors trained in other EU countries. Regarding nurses, the inflow of foreign-trained nurses fell

sharply between 2004 and 2009, but it has gone up since then, driven mainly by the migration of

nurses trained in other EU countries (e.g., Spain and Portugal), to meet growing demands for nurses

that are not fully met by the growing supply of domestically-trained nurses. It is important to keep in

mind that there are also large outflows of nurses trained in the United Kingdom, who are emigrating in

other English-speaking countries such as Australia, Canada, New Zealand and the United States

(Buchan and Seccombe, 2012).

0

4 000

8 000

12 000

16 000

20 000

24 000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

NumberDomestic graduates Foreign-trained

0

20 000

40 000

60 000

80 000

100 000

120 000

140 000

160 000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Number Domestic graduates Foreign-trained

18

Figure 4. Changes in the numbers of domestic graduates and inflow of foreign-trained health workers, United Kingdom, 2000-14

Doctors Nurses

Note: Between 2005 and 2008, data on staff trained abroad correspond to the administrative period ending 31 March of the year indicated. Break in 2008 for the graduate series. Data from 2008 onwards are estimated.

Source: UK Graduate Output 1991/92 to 2012/13, Health and Social Care Information Centre. Nursing and Midwifery Council.

In most OECD countries, the number of medical and nursing graduates is expected to continue to

rise in the coming years, possibly further reducing the need to recruit foreign-trained doctors and

nurses, unless the demand for their services exceeds the growth in domestic supply.

3.2 Impact of European Union enlargement on international mobility of health workers

The free movement of people and workers has been a cornerstone of efforts to build the EU since

the Treaty of Rome was signed in 1957. Prior to the accession of the ten new member countries in

2004, there were concerns about a possible massive inflow of health workers from these countries.

These concerns were based primarily on the results of surveys of health workers' intentions to migrate,

conducted before enlargement. For example, more than a third of Polish health workers and more than

half of Estonian health workers expressed their intention to emigrate to find work (Vörk et al., 2004).

Yet migration flows have been more modest, all things considered.

Following accession, a substantial number of Polish doctors obtained a registration in another EU

country in 2004, particularly in Germany (Figure 5). However, this number (fewer than 200) still

remained very low in comparison to the total number of doctors practising in Poland then (over

80 000). Furthermore, from 2005, admission plummeted and have remained very low, despite a slight

increase in recent years.

Since 2010, Polish doctors have been returning home in sizeable numbers. This trend may reflect

the substantial increase in doctors' incomes in Poland following the strikes in 2006/07, and the

increase in the financing of the health system.

0

2 000

4 000

6 000

8 000

10 000

12 000

14 000

16 000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Number Domestic graduates Foreign-trained

0

5 000

10 000

15 000

20 000

25 000

30 000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Number Domestic graduates Foreign-trained

19

Figure 5. Changes in numbers of new registrations of doctors trained in Poland in three OECD countries, 2001-12

Source: Professional registers.

Regarding nurses, the available information indicates that there was no sudden inflow of Polish

nurses in Western European countries in 2004. In the United Kingdom and Ireland, the flows appear to

have been affected more by labour market demand which grew up to 2007 before falling from 2008

onwards.

Romania is a country that joined the EU in 2007, and from which there are large outflows of

health workers. In Italy and to a lesser extent France, there have been steep increases in the

recruitment of Romanian health workers over the last 10 years. France has seen a steady inflow of

Romanian-trained doctors since 2007, when recognition of their professional qualifications became

easier following EU accession. In Italy, the migration of nurses trained in Romania started to grow

around 2002 before EU accession and reached its peak in 2007 at the time of EU accession (Figure 6).

While Italy limited access to its labour market to Romanian and Bulgarian citizens, these restrictions

did not include nurses; since 2002, foreign nurses have been exempted from annual quotas in response

to shortages.

0

20

40

60

80

100

120

140

160

180

200

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Germany Denmark Norway

20

Figure 6. Changes in numbers of new registrations in Italy and France of nurses trained in Romania,

2000-12 and 2006-12

Source: Professional registers.

3.3 Impact of the economic crisis and health spending reductions on international

migration of health workers in Europe

The economic crisis which started in 2008 in many OECD countries had varying effects on

international flows of migrant health workers. Some countries have recruited less international health

professionals as they cut health expenditure growth and some domestic-born health workers came

back on the job market. Some countries hardest hit by the crisis, mainly in Southern, Central and

Eastern Europe, experienced considerable outflows of health workers after 2008, with most of them

going to Germany and the United Kingdom. In some EU countries, this international mobility helped

to achieve a better balance on labour markets and reduced the risks of unemployment and under-

employment among health workers. Greece and Italy, two countries particularly hard hit by the crisis,

have since 2008 seen a significant increase in the numbers of doctors moving to other European

countries, notably Germany and the United Kingdom.

In recent years, Germany seems to be the favoured country of destination for doctors born in

Greece and Italy. The number of doctors of Greek nationality in Germany rose by 50% between 2008

and 2012, from slightly more than 1 700 to nearly 2 600. Doctors trained in Italy also headed for

France, the United Kingdom and Switzerland. At the same time, many German doctors emigrated to

other countries. In Switzerland, for instance, nearly 1 500 German-trained doctors were added to the

professional register between 2008 and 2012. The emigration of doctors from crisis-hit countries to

Germany might thus have served to offset the emigration of some German doctors.

As for nurses, there has been a steep rise in emigration from Spain, Portugal, Romania and Italy,

with the United Kingdom being the main destination country. Since 2009, nurses trained in these four

countries have represented the vast majority of new internationally registered nurses in the United

Kingdom.

3.4 Impact of bilateral agreements on the training and employment of health workers

0

500

1 000

1 500

2 000

2 500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Nurses registered in Italy trained in Romania Nurses registered in France trained in Romania

21

The WHO Global Code of Practice on the International Recruitment of Health Personnel

encourages Member States to put in place bilateral, regional or multilateral arrangements to promote

cooperation and coordination in the area of international recruitment (WHO, 2010). The Code

specifies, in particular, that these arrangements should take into account the needs of developing

countries and countries with economies in transition. In recent years, several OECD countries have

implemented such bilateral agreements for the international recruitment of health personnel.

For example, Germany concluded a bilateral agreement with Viet Nam in 2012, covering pilot

projects for the training and recruitment of geriatric care nurses in Viet Nam, a country identified on

the basis of its strategy of training nurses for the global market. The project was commissioned by the

German Federal Ministry of Economics and Technology (BMWi) and is being implemented by the

German cooperation agency, the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIz) in

collaboration with the Vietnamese Ministry of Labour, Invalids and Social Affairs. Some 100

Vietnamese nursing graduates were selected initially to take six months of training in the German

language and culture. Participants then travelled to Germany at the end of 2013 to begin two years of

professional training, accompanied by a programme of integration and language courses. This pilot

project seeks to establish a baseline for the future recruitment of skilled foreign personnel to provide

care in Germany (GIZ, 2014). At the same time, a project for recruiting nurses in China was launched

by the caregiving employers’ association, the Arbeitgeberverband Pflege. A bachelor’s degree, one

year of professional experience, and eight months of language and cultural training are the conditions

for participation in the programme. While awaiting recognition of their credentials, these Chinese

nurses work as nursing assistants. Germany expected to receive 150 Chinese nurses via this

programme in 2014.

The German authorities have also sought to ensure that, consistent with the principles of the

WHO Code of Practice, its international recruitment activities do not come at the expense of countries

of origin. During the July 2013 review of the list of professions in short supply in Germany, the

government prohibited the recruitment of health workers in the 57 countries identified by WHO in

2006 as facing a critical shortage. This decision was subsequently reconsidered, as it not only banned

active recruitment by an employer or private agency but also prevented health workers from seeking

employment in Germany at their own initiative (so-called passive recruitment). This provision was

finally eliminated with the revision in October 2013 of the employment ordinance, which now

prohibits active recruitment and the private placement of health workers from the 57 countries

mentioned.

In Finland, the Mediko programme (which stands for Recruitment of Foreign Health and Social

Care Professionals to Finland) was launched in 2008 and is still in place. Initially coordinated by the

municipality of Kotka, the Mediko project was then expanded to cover all of Finland. Since its

creation, Mediko has provided counselling to some 80 doctors, mainly Russian, wishing to practice in

Finland. Mediko has also begun to recruit nurses in Spain. Following an exploratory visit in 2012,

2 000 Spanish nurses expressed an interest in moving to Finland. Finnish language courses have been

organised in various Spanish cities, and since 2012, nearly 150 persons have been recruited via this

programme. With a view to longer-term recruitment, intensive language courses prior to departure are

planned as a way of bolstering the motivation to move. Mediko also promotes cooperation between

Finnish training institutions and Spanish, Russian and Estonian institutions.

These examples illustrate the proliferation of international recruitment initiatives in the health

field within the context of bilateral agreements. For the time being, the number of people involved in

these projects is still limited and represent only a very small proportion of doctors and nurses. They

may however play an important role if they are steered towards positions that are particularly difficult

22

to fill. Some stakeholders also believe that a recruitment campaign, once launched, may well grow

over time to reach a substantial number of candidates for immigration.

Another feature of several of the recruitment initiatives discussed here is the absence of historic,

colonial and linguistic ties that previously prevailed between countries of origin and countries of

destination. Countries are being increasingly targeted for recruitment in light of their strategy of

training health workers for the international market. Learning the language of the destination country

then becomes a central condition of success of such recruitment programmes.

There may also be a need to think about more ambitious approaches to bilateral and multilateral

agreements building on the recent example of the Paris Agreement in the area of climate change (Box

1).

Box 1. Learning from new models of global governance in the area of climate change

The Memorandum of Understanding to Enhance Cooperation on Climate Change, Energy, and the

Environment between the United States of America and the Government of the People’s Republic of China is a

powerful example of how bilateral agreements can be utilized to further cooperation on issues considered

intractable. While this MOU had little in area of substantive agreement, it formalized a high-level platform for

cooperation and dialogue on Climate Change between China and the United States (Dhillon, 2010). Similarly,

formalized dialogue-focused MOUs have proliferated in the Climate Change arena (e.g., partnership dialogues

established between the EC and Brazil, China, India, South Africa, and South Korea..8 The mutual

understanding and agreement facilitated by the US-China platform has since been credited, including by

President Obama, as being a major contributor to the successful adoption of the Paris Agreement on Climate

Change.

The Paris Agreement has been hailed by many as the new model for global governance (Slaughter, 2015;

Meyer, 2015). It aims to address an issue of global concern, with clear recognition of countries most

vulnerable. It also identifies ethical principles and standards associated with national, international, and global

effort. The Paris Agreement does not strictly represent binding international law with strict obligations.

Instead, it substitutes a strong focus on “compliance”, determination of legality or illegality, with an “enhanced

transparency framework”.

The Paris Agreement also incorporates Intended Nationally Determined Contributions (INDCs). Here

monitoring and accountability are linked to voluntary nationally determined commitments, which are to be

progressively raised. This voluntary individualized bottom-up approach to changing behaviour, as exemplified

in the Paris Agreement, is one that holds significant promise and can lead to deeper action than would

otherwise be possible.

A final, important, lesson from the Paris Agreement is a clear rejection of the idea of compensation.

While the Paris Agreement (through article 8) speaks to providing support to offset loss and damage in

countries threatened by climate change, the associated Paris Decision explicitly states that “Article 8 of the

agreement does not involve or provide any basis for liability or compensation.”

The Paris Agreement might provide some useful lessons for formalizing similar dialogue structures

through bilateral agreement between key source and destination countries for migrant health personnel.

23

Conclusions

Migrant health workers represent a significant share of doctors and nurses working in OECD

countries. The share of foreign-born doctors and nurses has increased in most OECD countries

between 2000/01 and 2010/11, and so did the share of foreign-trained doctors and nurses between

2000 and 2012-14, although it is worth noting that the share of foreign-trained doctors in the two main

destination countries – the United States and the United Kingdom -- has decreased slightly in recent

years, which is also most likely the case for foreign-trained nurses, mainly due to greater domestic

education and training efforts.

A large proportion of these foreign-born and foreign-trained doctors and nurses were born and

trained in other OECD countries (between one-fourth and one-third in 2010/11). Two Asian countries

are also important places of origin – India for doctors and the Philippines for nurses – although the

annual migration flows from these countries to OECD countries has decreased sharply in recent years.

The group of about 50 countries identified in 2006 as suffering from critical shortages have seen

their health workers continue to emigrate in growing numbers between 2000/01 and 2010/11.

Emigration therefore appears to have contributed to these critical shortages in these countries over the

past decade. It accounted for 20% of estimated critical shortages in 2010/11, compared with 9% in

2000/01. In the decade preceding the adoption of the WHO Global Code, the number of doctors and

nurses originating from countries with severe shortages who emigrated to OECD countries grew by

84%, while the total number of migrant health workers increased by 60%.

By adopting the WHO Global Code of Practice on the International Recruitment of Health

Personnel in 2010, all countries have committed to improving their health workforce planning and to

responding to their future needs without relying unduly on the training efforts of other countries, in

particular those already suffering from critical workforce shortages. The goal must not necessarily be

to achieve self-sufficiency, but to reduce the magnitude of reliance on other countries to fill domestic

needs.

Three possible areas for action in both destination and origin countries are proposed:

1. OECD countries should adjust their domestic education and training capacity to respond to

current and future projected demand where necessary, based on more robust health workforce

planning, and promote greater retention rates of currently active health professionals, to

reduce their demand on foreign-trained doctors and nurses.

2. Lower-income countries that are losing many of their skilled health workers need to address

some of the “push” factors by increasing their efforts to retain these scarce resources through

improving their working conditions and pay rates. These retention measures will require good

governance of the health system and long-term financial commitment, which in many cases

may require the support of the international community (Dieleman et al., 2009; Buykx et al.,

2010; Buchan et al., 2013), as called for by the WHO Global Code of Practice.

3. As called for by the WHO Global Code of Practice, both destination and origin countries

should also seek to better manage health workforce migration by negotiating mutually

beneficial bilateral agreements, including by possibly instituting a process of formalized

dialogue between key source and destinations countries . Up until now, most bilateral or

multilateral agreements have involved a fairly limited number of doctors and/or nurses.

However, if these agreements provide benefits for both origin and destination countries, there

is a potential to increase their scope in the years ahead.

24

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