Conflicting Narratives and Incomplete Policy Learning: Can circular migration improve African health outcomes?

Dr. Andrew Lawrence Centre of African Studies 21 George Square The University of Edinburgh Edinburgh EH8 9LD Andrew.Lawrence@ed.ac.uk*

"Migration Policy and Narratives of Societal Steering" workshop at the

University of Sussex, 18th - 19th September 2008 on:

Draft paper for the

'Narratives of migration management and cooperation with countries of origin and transit'

*DRAFT only: please do not circulate or cite without permission; comments welcome

Summary This paper considers the conflicting effects and changing rationale of two related policy areas: UK immigration policy with respect to non-EU nationals from Commonwealth countries in Africa, and NHS recruitment of health professionals from these countries. It argues that the narratives of migration policy and health policy conflict in ways that occlude development policy alternatives. It considers the applicability of recent policy initiatives to streamline and enhance migration flows through the promotion of circular migration to African migrant health workers in the UK. The European Commission (2007: 4) defines this policy as migration that is managed in a way allowing some degree of legal mobility back and forth between two countries with such advantages as: formalizing a migration relationship, improving data collection for sending and receiving countries, expanding capacity for and streamlining legal migration opportunities, and adopting measures that address and reverse brain drain. The realization of these advantages in the health sector would be of particular importance, given the acute crisis of healthcare in most African countries in the context of declining total employment in this sector among both developed and developing nations; and inability of African healthcare infrastructure development to keep pace with increases in population growth, disease burdens, as well as with the growing reliance of developed country health systems upon the recruitment of health workers from developing countries. With reference to recruitment in particular, the paper considers aspects of NHS policy that are distinctive among European cases; it further analyzes the role of South Africa as both an origin, target and transit country among health workers in the southern African region. The paper outlines the scope of African health worker migration to the UK over the past decade and the changes in migration policy that have accompanied it. It then identifies barriers to the successful implementation of a circular migration policy with reference to worker preferences, home country contexts, and policy constraints; examples of best practices; and concludes with a discussion of potential measures for addressing these barriers.

I. Scope of, and policies affecting, migration to the UK The politics of and disputes over health worker migration are not a new phenomenon. Alfonso Mejias observation (Mejia 1978: 207) three decades ago that The international flow of physicians and nurses is a significant, currently unpredictable, and largely uncontrolled movement which manifests a high rate of change in terms of size and direction remains equally valid today. Complaints that Britain poached health care workers are at least six decades old.1 What is new, however, is the global scale and scope of migration, with an increasingly complex pattern of movement; the emergence of a human rights discourse concerning patients and migrants alike; the number of international agreements to address the phenomenon; and the intensity of need in the most underserved world region, subSaharan Africa. The current dynamic of Northern countries reliance on Southern ones to fill a growing gap in core medical staffing, without ensuring that the level of medical services of Southern home countries is improved rather than degraded, is little better than neocolonial exploitation; nor is it, as I argue below, likely to be sustainable. The scope and intensity of the current African health care sector crisis needs little elaboration here. The figures in Table 1 show that in addition to the obvious NorthSouth divide, the discrepancies among African countries are as great or greater as those between Africa and the wealthiest OECD countries: Table 1 Country Total pop. physicians/1000 pop (2004) RSA 48m .77 Nigeria 130m .28 Malawi11m .02 Zimbabwe 12m .16 USA UK Canada
1

no. medical schools 8 15 1 1 156 32 17

300m 61m 34m

2.56 2.30 2.14

In 1948 the Executive Secretary of the International Council of Nurses wrote to the Chief Nurse in England complaining that English employers were actively recruiting nurses from the Netherlands at time when that country was trying to rebuild after World War II. Letter from Executive Secretary, ICN to Chief Nursing Officer, Ministry of Health, England, 20 August, 1948. Source: Public Records Office; quoted in Buchan (2002: 18).

Australia

21m

2.47

18

While South Africa has roughly a third of the physician per capita ratio of UK, Canada, Australia, and the U.S., and a quarter of their number of medical schools per capita, Malawi has half the medical school ratio and barely one fortieth of South Africas physician ratio.2 What is worse, disparities between urban and rural areas within African countries are often more severe. Particularly in southern Africa, these factors are exacerbated by the AIDS crisis, which decimates health care workers and drives many others from a dangerous and overstressed health delivery infrastructure. Based on current trends, the number of HIV patients per physician will soon overtake the absolute number of physicians treating HIV in Africa (Table 2): Table 23

For all these well-known reasons, a recent article in the Lancet declared that the active recruitment (often called poaching) of African health care workers is a crime.4 It argues that
Recruitment of health workers from Africa is a structured initiative led by recruitment organisations, but clearly sanctioned by countries that then accept these placements, such as Australia, Canada, Saudi Arabia, the UK, the United Arab Emirates, and the USA. Active recruitment is considered unethical under many national policies, leads to negative health outcomes, and undermines the right to health as asserted in the Universal Declaration of Human Rights, various International Covenants, and numerous declarations and legally binding treaties including the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination against Women. Customary international law suggests that such recruitment strategies cease. There are many statements and recorded declarations of state representatives indicating an international consensus that active health-worker recruitment is wrong and should not be propagated. The
2

While it is no longer the case that (in the oft-repeated observation from a quarter century ago) there are more Malawian physicians in Manchester than in all of Malawi, there are still more Malawian physicians living overseas than in Malawi, with at least as many (forty percent of the total) living in the UK (see Table 4, below). 3 Edward Mills, et al., Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime? The Lancet, Volume 371, Number 9613, 23 February 2008: 687. 4 The Lancet, Volume 371, Number 9613, 23 February 2008 lead editorial: 623.

Commonwealth Code of Practice for the International Recruitment of Health Workers, Melbourne Manifesto, the UK National Health Service's (NHS) code on ethical recruitment, and the World Medical Association Statement on Ethical Guidelines for the International Recruitment of Physicians, and the WHO task force against the brain drain, all clearly demonstrate awareness of the problems of health-worker migration from poor to richer countries. These statements set minimum standards to prevent exploitation of workforces in poorer countries, including equitable recruitment whereby recipient countries should receive new health workers only when there is compensation to the delivering state to contribute to health structure. 5

A policy favoring criminalization of this recruitment is, however, unconvincing and misguided, for the same reasons that the term poaching is inappropriate in this context. There is no effective transnational policing structure available to target the practice; if there were, it would merely drive it underground; and most important, this view marginalizes the agency of the migrant workers themselves. For similar reasons, nationally mediated bilateral agreements are likely to be either overly vague and toothless in their implementation, lacking any genuine regulatory capacity (especially regarding the private sector), or overly restrictive of the potential range of choices available to health workers (or, in the worst case, both). My argument, to the contrary of that of Lancet, that current and even increased levels of African health worker migration can be beneficial, may seem provocative. But I argue that in the proper context of continuing efforts at scaling up, bilateral agreements on recruitment and placement, and home country infrastructural improvement this policy can potentially contribute to the solution rather than the problem, at least in the short term. In order for this to be the case, however, the context of recruitment in the UK needs to be established, key data needs to be gathered and several assumptions need to be validated. Above all, the level of coordination between sending and receiving countries needs to be significantly increased, while making as the top priority the needs of the sending countries in question. Understanding why this hasnt yet happened requires a closer look at the conflicting narratives of NHS employment modernisation, immigration policy restructuring, and the management of development policy. These are outlined below.

II. Push and Pull factors emanating from within the UK: policy schizophrenia? The narrative of NHS employment modernisation should be understood in the context of increasing overseas recruitment to the NHS. Former Prime Minister Blair wanted to deliver on his campaign promise to improve the NHS and increase staffing upon election in 1997. Immigration became his principal means of achieving this goal. Due in part to the Labour manifestos stipulation that it would follow the previous Conservative governments spending plans during its first two years of office, as well as its strategy upon re-election in 2001 concerning public sector working practices and pay bargaining, real annual medical staff salaries increased barely 1.5 percent throughout his term of office (White 2004). Pay, work conditions and career
5

Edward Mills, et al., Should active recruitment of health workers from sub-Saharan Africa be viewed as a crime? Op. cit.: 685ff.

opportunities thus became comparatively more attractive to developing world professionals than their UK-born counterparts. For no developing world area was this more true than Africa, as Table 3 shows:

Table 3: New African health worker registrants/percentage of foreign registrants, 1990-20036

Clearly, not only were foreign-trained health workers an increasing presence within the NHS (with foreign doctors totaling forty percent in 2001 and foreign nurses averaging more than fifty percent since 1995), but also the rate of increase for African doctors (since 2001) and nurses (since 1998) has been higher than that of other foreign workers. While this pattern applies to countries other than the UK, the UK bears particular responsibility for the effects of migration from most eastern and southern African countries. The most complete and up-to-date data on African health worker migration (Clemens and Petterson 2006) shows that as of 2000, the UK was the principal receiving country for physicians born in Botswana (forty percent of overseas, five percent of the total number), Malawi (66%, 40%), South Africa (45%, 10%), Tanzania (55%, 28%), and Zambia (55%, 33%), among others; and the principal receiving country for nurses born in all of these countries as well as Nigeria and Zimbabwe (see Tables 4 and 5, below). While the proportions of nurses abroad and in the UK are not as great as those for physicians, in the case of Zimbabwe, for example, they represent almost three-quarters of the total abroad and almost twenty percent of the total number of Zimbabwe-born nurses, respectively.

Pond, B. and B. McPake (2006) The health migration crisis: the role of four Organisation for Economic Cooperation and Development countries. Lancet; 367: 1450.

Table 4. Physicians born in Africa appearing in census of top five receiving countries circa 20007
Sending country Domestic total 530 114 200 466 30,885 27,551 133 1,264 670 1,530 280,808 96,405 GBR 28 8 191 37 1,997 3,509 4 743 465 553 15,258 13,350 USA 10 0 40 15 2,510 1,950 4 270 130 235 12,813 8,558 Receiving country CAN 0 0 0 30 120 1,545 0 240 40 55 3,715 2,800 AUS 3 0 10 9 0 1,111 0 54 39 97 2,140 1,596 ZAF 26 49 48 291 180 834** 44 40 203 643 1,459 1,434 68 57 293 382 4,856 7,363 53 1,356 883 1,602 64,941 36,653 11% 33% 59% 45% 14% 21% 28% 52% 57% 51% 19% 28% Total abroad Frac.*

Botswana Lesotho Malawi Namibia Nigeria South Africa Swaziland Tanzania Zambia Zimbabwe Africa Sub-Saharan

Table 5. Professional nurses born in Africa appearing in census of top five receiving countries c. 20008
Sending country Botswana Lesotho Malawi Namibia Nigeria South Africa Swaziland Tanzania Zambia Zimbabwe Africa Sub-Saharan Domestic total GBR 3,556 1,266 1,871 2,654 94,747 90,986 3,345 26,023 10,987 11,640 758,698 414,605 47 5 171 18 3,415 2,884 21 446 664 2,834 20,647 20,372 USA 28 6 171 6 8,954 877 36 228 299 440 20,983 19,545 Receiving country CAN 0 0 10 0 160 275 10 240 25 35 1,865 1,690 AUS 0 0 14 4 0 955 4 32 68 219 1,828 1,724 ZAF 5 25 11 118 12 261** 25 4 52 178 239 239 80 36 377 152 12,579 4,844 96 953 1,110 3,723 69,589 53,298 2% 3% 17% 5% 12% 5% 3% 4% 9% 24% 8% 11% Total abroad Frac.*

*Gives the number of professionals abroad as a fraction of total professionals (domestic + abroad), including four other receiving countries (Belgium, France, Portugal, and Spain) not listed here. **There are 834 physicians and 261 nurses born in one of the other eight receiving countries who appear in the 2001 census of South Africa. This negative number thus represents a netting out term.

Furthermore, given the increased recruitment since 2000, it is likely that these figures understate the true totals, in which African migrants may constitute more than ten percent of UK-based nurses and fifteen percent of doctors. For this reason, the full extent of African health worker migration to the UK needs to be established. In 2003, UK work permits were approved for 5880 health and medical personnel from South Africa, 2825 from Zimbabwe, 1510 from Nigeria, and 850 from Ghana, despite these countries being included among those proscribed for NHS recruitment.9 Although all
7

Michael A. Clemens, Gunilla Petterson, 2006. New data on African health professionals abroad. Washington, DC: Center for Global Development Working Paper, August 2006: 22-23. 8 Ibid. 9 J. Eastwood et al., 2005. Loss of health professionals from sub-Saharan Africa: the pivotal role of the UK. The Lancet, Volume 365, Issue 9474, 28 May 2005-3 June 2005: 1893-1900.

physicians and nurses need to be registered with their respective UK professional organizations, there are several reasons why this data is incomplete, including changed professions, changed student-practitioner status, and the exploitation of loopholes by private recruitment agencies. Most important of these, private recruitment agencies and privatised provision can limit the effectiveness of bilateral controls because private flows are not covered (Word Health Report 2006, p105). Indeed, private recruitment and provision are features of the NHS Plan. According to Young et al (2003), a global recruitment campaign was launched by the DH in August 2001 aimed particularly at shortage medical specialties and specialties where significant expansion will be needed in order to meet targets set out in the NHS Plan. The programme was administered by the private recruitment agency TMP Worldwide and the campaign had a substantial impact on flows of health workers to the UK. According to Pond and McPake (2006), The number of newly registered, foreign-trained physicians doubled by 2003, and from 1997 to 2003 almost three-quarters of the increase in NHS nurses came via international recruitment. NHS Plan implementation also includes increased private provision in all sectors. This commercialisation has spurred increases not only in health worker migration but also in the proportion of migration that is privately controlled. According to the ILO (2004: 96) the practice of shopping overseas for specialized skills has grown (bodyshopping), and labour markets for some highly skilled professionals are effectively already global. The globalization of higher education systems has reinforced this trend. In response to criticisms of these recruitment practices, in 1999 the Department of Health issued the first of several ethical guidelines for health worker recruitment, proscribing active advertisement, discrimination, and related issues. There is reason to doubt, however, that the ethical guidelines proscribing active recruitment of professionals from 1999 have had a significant impact. While a few sending countries registered a slight dip in medical registrants after one year, in most cases, the previous levels were attained or exceeded in following years, as Table 6 shows. Further, both officials and applicants in developing countries do not perceive the Guidelines as a deterrent, with applicants from Ghana, Kenya, Malawi, and Zambia posting steady increases (Mesquita & Gordon 2005).
Table 610 Registrants from selected countries, "before" and "after" implementation of the ethical recruitment guidelines in November 1999

Country

1998/9 9

1999/20 00

2000/2001

% change,

% change,

% change

10

Stilwall et al. 2003: 10.

1998/99 to 1999/200 0 South Africa West Indies Zimbabwe Ghana India Nigeria Philippine s 599 221 52 40 30 179 52 1460 425 221 74 96 208 1052 1086 261 382 140 289 347 3396 +144 +92 +325 +85 +220 +16 +1923 (+65)

1999/20 00 to 2000/01 -25 -39 +73 +89 +201 +67 +223 (+40)

2000/01 to 20001/2 +95 -5 +24 + 39 + 244 + 25 + 113 + 63

(Total (3621) (5988) (8403) non-EU registrant s) Source: UKCC (now Nursing and Midwifery Council)

In line with the trend towards explicitly linking immigration policy with global market considerations, the Highly Skilled Migrant Programme (HSMP) was introduced in January 2002 to attract ' high human capital individuals, who have the qualifications and skills required by UK businesses to compete in the global marketplace' (Para 2.18, 2002 White Paper). This scheme allocates points for educational qualifications, age, salary and UK Experience or UK Study; it originally included health care professionals who usually had little difficulty achieving enough points for entry. In 2007, however, the UK changed its migration rules by removing the exemption from immigration controls health workers formerly enjoyed. The effects of this policy change are to restrict public authority recruitment to EU countries and to reduce non-EU migrants to guest worker status. Then in February 2008 the Home Office announced that non-EU doctors or international medical graduates (IMGs) will not be eligible for the highly skilled migrant programme (HSMP). Further, the Department of Health proposed that those already working in the UK with HSMP status will only be allowed to take such jobs if no UK or EU doctor is available (although this is currently subject to appeal in the House of Lords). Most recently, as of February 29th 2008 all in country applicants need to apply for the new General Highly Skilled Migrant Programme (GHSM) based on the HSMP.11

11

http://www.internationalworkpermits.com/uk-hsmp.html accessed March 12, 2008

It is unclear what precise effects on migration flows the changes in eligibility factors for non-EU migrants such as those from Africa will have. Obviously, their net effect will be negative, discouraging further immigration from these professions. But the changes may also spur a rise in citizenship applications among the affected population. It is also not clear what proportion of African migrant health workers currently resident in the UK are eligible to pursue permanent residency or citizenship, much less what the movements of the ineligible population will be. III. New data to be collected But these changes do not reduce the need to collect data. On the contrary, it remains of vital interest to policy makers concerned with maximizing health outcomes in African sending countries whether those migrant health workers whose status is recently and negatively changed will be more likely to return home or move elsewhere; and if they do return, whether they will continue work in the health sector. If shifts in residency status have a negative impact on the likelihood of health workers remaining in their professions, the policies should be reconfigured with these consequences in mind. Second, once these numbers are established for the past decade, it is important to disaggregate the reasons for migration by the migrants profession, specialization, age, gender, and country and region of origin. A global list of push and pull factors are well known (including home country salaries, benefits, work conditions, opportunities for advancement, political conditions, life stage, and family status), but the relative importance among them is necessary to establish in order to construct a hierarchy of preferences that could inform policy incentives. This data should also try to include voluntary assessments of remittance flows, whose extent in this sector is unknown but is likely to be significant. Third, the effects of the current bilateral agreements need to be assessed. To date, the only sub-Saharan African country with which the UK has established a Memorandum of Understanding is South Africa in 2003. Given the relative economic and political advantages South Africa enjoys over most other African countries, this Memorandum thus serves as a test case for the effectiveness and fairness of such agreements. British Health Secretary John Hutton promised to strengthen the International Code of Practice on Ethical Recruitment of Health Workers, adopted by Commonwealth countries at the World Health Assembly in Geneva in 2003; that the UK would close loopholes in the code that allowed health-care providers to bring in staff from developing countries, including back-door recruitment into the NHS via the private sector; and that the code would be extended to the recruitment of all health workers, and not only to those employed on a full-time basis. While six percent of NHS employees are of South African origin, and the South African public sector still suffers from a thirty-five percent vacancy rate, the rate of recruitment has recently fallen off. Between January and July 2003, 1,600 nurses had applied to the Nursing Council to have their qualifications verified for work overseas, whereas in the same period for 2004, 1 100 10

nurses had applied, a decrease of about one third. Further analysis needs to establish whether this is a temporary drop-off, as with the Ethical Guidelines, or a growing trend. If the latter, however, the MoU may represent a significant step backward in one key regard: if increased regulation serves as a disincentive for new entrants to the profession, who perceive their presumed career ladders being shortened as a consequence, then the significant recent gains in attracting greater numbers of students into the health professions could be reversed. Is this were to happen, it would be as much or more to the detriment of home countries such as South Africa as to receiving countries such as the UK. The memorandum also encourages the creation of education and practice opportunities for local health workers for specific periods within the NHS. It is therefore only a small conceptual step to move from encouraging practice opportunities for discrete periods, and encouraging them on a structured and continuous basis, whereby African immigrants would return to their home countries for specific periods of time, funded through bilateral and multilateral sources and placed perhaps on a points system similar to the one the UK has recently borrowed from Canada and Australia to sectors and regions of greatest need. There are preliminary data to suggest that this opportunity would be attractive to many current African migrants, in particular when coupled with national programmes of health infrastructure rebuilding. Part of the attraction as well would be the voluntary nature of the programme, so that workers would only choose to repeat a stint if they wished to do so and would otherwise maintain their UK status. This is similar to the approach of the International Organization on Migrations project Migration for Development in Africa (MIDA), begun in 2001. However, none of the eastern or southern African countries under review here have yet to develop a National Indicative Programme (NIP) under MIDAs auspices; and Namibia is the only country in these regions to take formal steps toward adoption of a NIP.12 IV. Barriers to circular migration Comparative experience suggests that circular migration regimes are most likely between or among countries with the most similar levels of sociocultural development. In this regard, adopting such a policy for African migrant workers to the UK seems at first an unlikely option. Two factors, however, mitigate this unlikelihood: the long historical ties former colonies have with the UK and the often sizeable immigrant populations currently resident in the UK, combined with the high professional standing of this specific migrant population. While a specifically tailored multiple entry visa system by the governments in question is probably the most durable and fairest basis of circular migration, less comprehensive policies can still have positive effects,
12

Countries that have inscription of MIDA in the National Indicative Programme (NIP) include: Benin, Cape Verde, DRC, Ghana, Kenya, Rwanda, Uganda; countries having taken formal steps toward the inscription of MIDA in the NIP include: Burkina Faso, Burundi, Djibouti, Eritrea, Ethiopia, Gabon, Liberia, Mali, Namibia, Nigeria; and those that have expressed interest in MIDA are: Cte d'Ivoire, Guinea-Bissau, Niger, Sao Tome et Principe, Sierra Leone, Somalia, Sudan, Zambia. See http://www.iom.int/MIDA/map.shtml accessed March
12, 2008

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complementary to circular migration, in promoting health worker flows.13 Open and free recruitment regimes that maintain high standards of transparency and accountability have the great advantage of providing incentive structures for African students considering entering the health professions that otherwise would not be as pronounced or extensive. Thus the sudden policy shifts in the UK and its posture of schizophrenia in attracting then repulsing migrant workers may have very negative longer-term impacts on the expansion of the total pool of African health sector workers at the precise moment when their need is most acute. There may be several push factors that render a circular migration policy less feasible. Migrants who start families in the receiving country may be less likely to want to disrupt schooling with a return home, particularly when the home schooling opportunities are less attractive. Workers who achieve the pinnacle of their professions may have no desire to return to the home or receiving country, depending on where they are based. Sudden political or environmental changes may alter the hierarchy of preferences equally suddenly. Indeed, the field of migration is one where prior assumptions about social behavior and political preferences are constantly subverted through new developments. Given the number of relevant actors and variables involved, policy makers need to develop complex models that allow for a multiplicity of outcomes. For this reason, the scenario method (see Bernstein et al. 2007: 229ff.) is particularly suited to this subject. Policy makers need constructive ways to think about the future and parse out the uncertainties in an inherently unpredictable setting. Scenarios make contingent claims and raise the possibility and plausibility of multiple futures, building on different combinations of causal variables that may also take on different values in different scenarios. A good scenario is an internally consistent hypothesis about how the future might unfold, whose foundation is made up of provisional assumptions and causal claims. These become the subject of revision and updating more than testing. A set of scenarios often contains competing or at least contrasting assumptions. Scenarios allow researchers to combine general knowledge of politics with expert knowledge of individual actors and situations, to build in context, complexity, variation and uncertainty in the form of multiple narratives with numerous branching points, and to revise their expectations as events unfold. Repeated iterations of this process can reasonably be expected to improve researchers ability to track specific developments and the outcomes that result, and their capacity to address the problems that these evolutionary tracks create. V. Conclusion: Combining scenarios with market incentives I would argue that a scenarios approach can combine with a points system incentive structure, devised through bilateral agreements between home and recipient countries, in order to better address migrant health workers shifting sets of preferences with the needs of both home and recipient country health systems. It could entail funded returns
13

These include hospital twinning programmes whereby UK hospitals adopt sister institutions in various African countries; student exchanges; and increased scholarships for African students.

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of African immigrants in the UK in monthly increments determined by the wishes of the migrant in question, the financial or other incentives entailed, and the need of the home country. These could be fine-tuned to maximize the number of worker-hours repatriated to the home country while not seriously affecting the overall staffing levels in the UK. A relatively small degree of repatriation from the smaller countries with a disproportionate presence in the UK, such as Malawi, Lesotho, Swaziland, Zambia or Zimbabwe, could nonetheless have a major positive impact to these countries health delivery systems, allowing them more latitude to expand. The incentives for UK policy makers are perhaps less obvious. But this may be the least bad option among threats of legal sanction and criminalization of vital sources of employment. In the longer term, as well, this could be a major asset in maintaining and increasing the UKs global competitiveness in recruiting and retaining health workers, while at the same time increasing staffing in home countries. A vicious cycle could thereby be transformed into a virtuous one. As Mejia concluded thirty years ago, the self interest of the affluent countries can be secured only if it is merged with a growing enlightened regard for the global interest (Mejia 1978: 215).

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