Migration patterns of physicians and nurses: still the same story?

Abstract

The publication of Alfonso Mejia's landmark study of physician and nurse migration in the late 1970s remains the most detailed analysis of the flows and stocks of the physician and nurse workforce, incorporating data from more than 40 countries (1). The study was undertaken by WHO because, as Mejia notes, "anxiety evoked by migration had reached a peak in both major donor and recipient countries". In the post-colonial period, developing countries were starting to expand their health services and to train their own nationals to fill the posts, but were confronted by a "brain drain". These developments coincided with the rapid expansion of health systems in industrialized countries and a shortage of professional staff to meet requirements, fostering the movement of health professionals between developing and developed countries. Although Mejia's study is remembered mainly because of its attempt to quantify the stocks and flows of physicians and nurses between donor and recipient countries, its remit was more ambitious. It developed a number of propositions that explored the relationship between GDP, the production of physicians and the likelihood that physicians would emigrate. In view of his position in WHO as Chief Medical Officer of Health Manpower Systems, Mejia was concerned to move beyond documenting trends, and his study was centrally concerned with the policy implications of migration (2). In 1972, about 6% of the world's physicians (140 000) were located elsewhere than in their countries of origin. Over three-quarters of them were found in only three countries: in order of magnitude, the United States of America, the United Kingdom and Canada. The then Federal Republic of Germany and Australia were the next most important recipient countries. The main donor countries reflected colonial and linguistic ties, with a dominance of Asian countries: India, Pakistan and Sri Lanka. At the same time, some countries--Canada, Germany and the UK--were both key recipient and donor countries. For nurses, it was estimated that about 135 000 (4% of the world's stock) were outside their country of birth or training. The Mejia study has aged well, and many of the insights remain as relevant today as when they appeared 25 years ago. Mejia highlights the lack of reliable data and the difficulties of defining whether a migrant is "permanent" of "temporary". Data limitations were exacerbated by the complexities of the migration pathways followed by physicians and nurses. In some cases labour migration took place directly from country to country, while in others it occurred in stages, with intermediate destinations complicating the interpretation of migration patterns. Mejia notes that government information on migrant inflows is more reliable than that on outflows, and this difference continues to the present day. The establishment of accurate data on stocks and flows of health workers remains a challenge that continues to inhibit effective migration management. Despite these difficulties, as the WHO study pointed out, data limitations should not be used to justify government inaction. The failure of workforce planning within donor and recipient countries, which Mejia attributed in part to a lack of political will to deal with underlying problems, continues to resonate with current concerns about imbalances in the health workforce (3). The Mejia study provides an important benchmark against which to consider current trends in health worker migration. A number of trends are discernible. Most importantly, the health sector has been a major component of the increased number of international migrants that has more than doubled since 1975 to an estimated 175 million people (2.9% of the world's population), of which an increasing proportion are women (48%) (4). Whereas cultural des were a key determinant in explaining migration pathways in the 1970s, an important facet of the globalization of health labour markets is that these historical ties are loosening as recipient countries become more utilitarian in encouraging migration primarily on the basis of economic requirements. …