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ippr’s Tim Finch and Sarah Mulleyrecently argued in Public Policy Researchthat the public debate on migration tothe UK has lacked ‘a strong articula-tion of a progressive centre ground

which recognises the benefits of migration,but which does not ignore the costs …understand[ing] that the rights of migrantsneed to be respected, but also that govern-ment needs to be able to enforce the UK’sright to determine who comes into the coun-try – and who remains here’ (Finch andMulley 2009: 120). This article agrees witheach of these points and seeks to push themfurther, in the context of the migration ofhighly skilled African health workers.

The NHS and British citizens more gen-erally need to recognise their establisheddependence on health workers from thesepoor sending countries, which looks likelyto continue for the foreseeable future. Theyshould further recognise that for many ifnot most of these sending countries, theaddition or subtraction of a single doctor ornurse can have a much greater impact onhome country health outcomes than on UKhealth outcomes. Finally, policymakersshould explore the possibility that well-

planned ‘circular migration’ can shiftrecruitment from being a ‘zero-sum’ to a‘positive-sum’ relationship between sendingand recruiting countries.

The European Commission (2007: 4)describes the advantages of ‘migration thatis managed in a way allowing some degreeof legal mobility back and forth betweentwo countries’ as including the formalisationof a migration relationship, improving datacollection for sending and receiving coun-tries, expanding capacity for and streamlin-ing legal migration opportunities, andadopting measures that address and reversebrain drain. This necessitates a policy shiftthat requires working with sending countrygovernments to maximise rather thandelimit the choices migrant doctors andnurses currently face.

The potential advantages of open-endedcircular migration for receiving countriessuch as the UK include more flexible, accu-rate, and longer term staffing, newapproaches to development assistance forsending countries, and improved healthoutcomes. For sending countries, benefitswould include better planning and data onmigrants, maintaining or increasing health

‘Circular�migration’and�the�potentialto�improve�healthoutcomesThe�UK�has�the�potential�to�strengthen�and�stabiliselonger-term�staffing�for�the�National�Health�Servicewhile�observing�and�building�on�its�commitments�torecruit�ethically,�in�ways�that�would�not�adversely�affecthealth�outcomes�in�the�sending�countries.�However,�todo�so�requires�a�new�approach,�explains�AndrewLawrence.�

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workforce staffing through the predictableavailability of overseas career ladders andremittance income, and the migrants them-selves would benefit from more flexible andsecure work arrangements, increasedoptions for residency and training, andenhanced ability to balance income withnon-income considerations.

For such a ‘triple-win’ scenario to be fullyrealised, however, UK policymakers in sepa-rate branches of government need to devel-op creative connections among migration,health and development policy, as well asgather more extensive data and engage inlonger term planning. Although NHSstaffing has (justifiably) been a central pre-occupation of Whitehall’s over the pastdecade, it has been inattentive to the exter-nalities that its increased reliance on amigrant workforce has created, and indeedhas failed to collect adequate data on thisand related areas, thereby seriously crip-pling its capacity for planning beyond theshort term.

In the first instance it would be prudentto confine a pilot policy to smaller sendingcountries in order to monitor its effects.Fortuitously, many of these smaller sendingcountries in Africa are also those with theheaviest disease burdens, suggesting that asuccessfully implemented pilot projectcould yield immediate and significantresults.

African�health�workermigration�to�the�UKDisputes over health worker migration andrecruitment are not a new phenomenon.Complaints that Britain ‘poached’ health

care workers are at least six decades old(Buchan 2002). What is new, however, is theglobal scale and scope of migration, with anincreasingly complex pattern of movement;the emergence of a human rights discourseconcerning patients and migrants alike; thenumber of international agreements toaddress the phenomenon; and the intensityof need in the most underserved worldregion: Sub-Saharan Africa. The currentdynamic of developed countries’ relianceon developing nations to fill a growing gapin core medical staffing, without ensuringthat the level of medical services of develop-ing home countries is improved rather thandegraded, is neither ethical nor sustainable.Fortunately, however, there is an alternativeto both intermittent recruitment and a com-plete embargo of the recruitment from themost vulnerable countries.

The crisis of acute health burdens andchronic understaffing African countries faceis well known. While South Africa hasroughly a third of the physician per capitaratio of the UK, Canada, Australia or theUS, and a quarter of their number of med-ical schools per capita, Malawi has half themedical school ratio and barely one fortiethof South Africa’s physician ratio. Disparitiesbetween urban and rural areas withinAfrican countries are often severe.Particularly in southern Africa these factorsare exacerbated by the AIDS crisis, whichdecimates health care workers and drivesmany others away from a dangerous andoverstressed health delivery infrastructure.

For all these reasons, a recent Lancet edi-torial declared the active recruitment (oftencalled ‘poaching’) of African health careworkers to be a ‘crime’ (Mills et al 2008).However, this view marginalises the agencyof the migrant workers themselves. And,nationally mediated bilateral agreementsbecome paper tigers when implementedwithout ongoing monitoring of effective-ness, adequate resourcing, accountabilityand legitimacy, thus lacking any genuineregulatory capacity (especially regardingthe private sector).

My counter-argument, that current andeven increased levels of African health

UK�policymakers�in�separatebranches�of�government�needto�develop�creativeconnections�among�migration,health�and�developmentpolicy

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worker migration can be beneficial, mayseem provocative. But in the proper contextof continuing efforts at scaling up, bilateralagreements on recruitment and placement,and home country infrastructural improve-ment, this policy can potentially contributeto the solution rather than the problem, atleast in the short term.

In order for this to be the case, however,the context of recruitment in the UK needsto be established, key data needs to be gath-ered and several assumptions need to be val-idated. Above all, a significant increase inthe level of coordination between sendingand receiving countries is required, and theneeds of the sending countries in questionmade top priority. Understanding why thishas not happened yet requires a closer lookat immigration policy restructuring and themanagement of development policy.

The mandate of the last government,under Labour, to improve NHS staffingdepended to a great extent on sharplyincreased overseas recruitment. For no partof the developing world was this more truethan for Africa. Not only were foreign-trained health workers an increasing pres-ence within the NHS (with foreign doctorstotalling 40 per cent in 2001 and foreignnurses averaging more than 50 per centsince 1995), but also the rate of increase forAfrican doctors (since 2001) and nurses(since 1998) has been higher than that ofother foreign workers.

Health�worker�migrationfrom�specific�AfricancountriesWhile this pattern applies to countries otherthan the UK too, the UK bears particularresponsibility for the effects of migrationfrom many Eastern and Southern Africancountries. The most complete and up-to-date data on African health worker migra-tion (Clemens and Petterson 2006) showsthat as of 2000, the UK was the principalreceiving country for physicians born inBotswana (40 per cent of the latter’s over-seas migrant physicians, 5 per cent of thetotal number), Malawi (66 per cent, 40 per

cent), South Africa (45 per cent, 10 percent), Tanzania (55 per cent, 28 per cent),and Zambia (55 per cent, 33 per cent). TheUK was also the principal receiving coun-try for nurses born in all of these countriesas well as for Nigeria and Zimbabwe. Whilethe proportions of nurses abroad and in theUK are not as great as those for physicians,in the case of Zimbabwe, for example, theyrepresent almost three-quarters of the totalabroad and almost 20 per cent of the totalnumber of Zimbabwe-born nurses, respec-tively.

Not only does the UK employ between aquarter and a third of all African doctorsand nurses working outside their homecountries, but for Sub-Saharan Africa thesefigures are closer to 40 per cent of the over-seas workforce. If half of all the doctors andnurses from Botswana, Malawi, Tanzania,Zambia and Zimbabwe who are currentlyresiding in the UK were to return to theirhome countries to practise, the UK wouldlose fewer than 1 per cent of its workforcebut the home countries would gain 20–40per cent of their total overseas workforces,in some cases 20 per cent of their combineddomestic and international workforce.

Despite declines in migration of Africanhealth professionals into the UK since 2008,it is likely that these figures understate thetrue totals. African migrants may constitutemore than 10 per cent of UK-based nursesand 15 per cent of doctors, given theincreased recruitment between 2000 and2008. In 2003, UK work permits wereapproved for 5,880 health and medical per-sonnel from South Africa, 2,825 fromZimbabwe, 1,510 from Nigeria, and 850from Ghana, despite these countries beingincluded among those proscribed for NHSrecruitment (Eastwood et al 2005).Although all physicians and nurses need tobe registered with their respective UK pro-fessional organisations, there are several rea-sons why this data is incomplete, includingindividuals changing professions, changingstudent-practitioner status, and theexploitation of loopholes by private recruit-ment agencies. Most important of these, pri-vate recruitment agencies and privatised ©

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provision can limit the effectiveness of bilat-eral controls because in most cases privateflows are not covered (Word Health Report2006).

In response to criticisms of these recruit-ment practices, in 1999 the UK’sDepartment of Health issued the first ofseveral ‘ethical guidelines’ for health work-er recruitment, proscribing active advertise-ment, discrimination and related issues.However, their impact is questionable.While a few sending countries registered aslight dip in medical registrants after oneyear, in most cases, the previous levels wereattained or exceeded in following years.Further, neither officials nor applicants indeveloping countries perceive the guide-lines as a deterrent, and there have beensteady increases in the number of appli-cants from Ghana, Kenya, Malawi andZambia (Mesquita and Gordon 2005).

In line with the trend towards explicitlylinking immigration policy with globalmarket considerations, the Highly SkilledMigrant Programme (HSMP) was intro-duced in January 2002 to attract ‘highhuman capital individuals, who have thequalifications and skills required by UKbusinesses to compete in the global market-place’ (para 2.18, 2002 White Paper). Thisscheme allocates points for educationalqualifications, age, salary and UK experi-ence or UK study. It originally includedhealth care professionals who usually hadlittle difficulty achieving enough points forentry.

In 2007, however, the UK removed theexemption from immigration controls thathealth workers formerly enjoyed. Theeffects of this policy change are to restrictpublic authority recruitment to EU coun-tries and to reduce non-EU migrants toguest worker status. Then in February 2008the Home Office announced that non-EUdoctors or international medical graduates(IMGs) would not be eligible for the highlyskilled migrant programme (renamed inApril 2009 as the Tier-1 General HighlySkilled Migrant [GHSM] sub-category). Asof February 2008, all in-country applicantsneed to apply for the GHSM (IWP 2009).

It is unclear what precise effects thechanges in eligibility factors for non-EUmigrants will have on migration flows.Obviously, their net effect will be negative,discouraging further immigration fromthese professions. But the changes may alsospur a rise in citizenship applicationsamong the affected population. It remainsof vital interest to policymakers concernedwith maximising health outcomes inAfrican sending countries as to whetherthose migrant health workers whose statusis recently and negatively changed will bemore likely to return home or move else-where; and if they do return, whether theywill continue to work in the health sector.

The effects of the current bilateralagreements need to be assessed. To date,South Africa is the only Sub-SaharanAfrican country with which the UK hasestablished a Memorandum ofUnderstanding (in 2003). Given the rela-tive economic and political advantagesSouth Africa enjoys over most otherAfrican countries, this Memorandumserves as a test case for the effectivenessand fairness of such agreements. Whenhe was UK Secretary of State for Health,John Hutton made a number of promisesaround strengthening the InternationalCode of Practice on Ethical Recruitmentof Health Workers, adopted byCommonwealth countries at the WorldHealth Assembly in Geneva in 2003: thatthe UK would close loopholes in thecode that allowed healthcare providers tobring in staff from developing countries,including ‘back-door’ recruitment intothe NHS via the private sector; and thatthe code would be extended to therecruitment of all health workers, and notonly to those employed on a full-timebasis. While 6 per cent of NHS employ-ees are of South African origin, and theSouth African public sector still suffersfrom a 35 per cent vacancy rate, the rateof recruitment has recently fallen off.Between January and July 2003, 1,600South African nurses applied to theNursing Council to have their qualifica-tions verified for work overseas, decreas- ©

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ing by about one third to 1,100 in thesame period for 2004.

Further analysis needs to establishwhether this is a temporary drop-off or agrowing trend. If it is the latter, the

Memorandum may represent a significantstep backwards in one key regard: ifincreased regulation serves as a disincen-tive for new entrants to the profession, whoperceive their presumed career ladders arebeing shortened as a consequence, then thesignificant recent gains in attracting greaternumbers of students into the health profes-sions could be reversed. If this were to hap-pen, it would be as much or more to thedetriment of home countries such as SouthAfrica as to receiving countries such as theUK.

The Memorandum also encourages thecreation of education and practice opportu-nities for local health workers for specificperiods within the NHS. It would only be asmall conceptual step to encouraging theseopportunities on a structured and continu-ous basis. African immigrants would returnto their home countries for specified peri-ods of time, funded through bilateral andmultilateral sources, and placed – perhapsvia a ‘points-based system’ similar to theone the UK has recently borrowed fromCanada and Australia – to sectors andregions of greatest need.

There are preliminary data to suggestthat this opportunity would be attractive tomany current African migrants, in particu-lar when coupled with national pro-grammes of health infrastructure rebuild-ing, and also given its voluntary nature.

How�would�‘circularmigration’�improveoutcomes?Circular migration is most likely to occurbetween or among countries with similarlevels of socio-cultural development. In thisregard, adopting a policy along the linesdiscussed for African migrant workers tothe UK seems at first an unlikely option.However, the long historical ties formercolonies have with the UK and the oftensizeable immigrant populations currentlyresident there, combined with the high pro-fessional standing of this specific migrantpopulation, somewhat mitigate this factor.While a specifically tailored multiple entryvisa system by the governments in questionis probably the most durable and fairestbasis of circular migration, less comprehen-sive policies can still have positive effects,complementary to circular migration, inpromoting health worker flows. Theseinclude hospital ‘twinning’ programmeswhereby UK hospitals adopt sister institu-tions in various African countries, studentexchanges, and more scholarships forAfrican students.

Open and free recruitment regimes thatmaintain high standards of transparencyand accountability provide incentive struc-tures for African students considering enter-ing the health professions that otherwisewould not be as pronounced or extensive.Sending country enrolments in medicaltraining programmes have increased in tan-dem with, and largely in response to,increased levels of UK recruitment. Thusthe UK’s sudden policy shifts in attractingthen deterring migrant workers may havevery negative longer-term impacts on theexpansion of the total pool of Africanhealth sector workers at the precise momentwhen their need is most acute.

I would argue that a ‘circular migration’system can combine with a ‘points-basedsystem’ incentive structure, devised throughbilateral agreements between home andrecipient countries, in order to betteraddress migrant health workers’ shifting setsof preferences within the needs of bothhome and recipient country health systems.

Open�and�free�recruitmentregimes�that�maintain�highstandards�of�transparencyand�accountability�provideincentive�structures�forAfrican�students

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It could entail funded returns of Africanimmigrants in the UK in monthly incre-ments determined by the migrants’ ownwishes, the financial or other incentivesnecessary, and the needs of the home coun-try. These could be fine-tuned to maximisethe number of workers repatriated to thehome country while not seriously affectingoverall staffing levels in the UK. A relative-ly small degree of repatriation from thesmaller countries that have a dispropor-tionate presence in the UK, such asMalawi, Lesotho, Swaziland, Zambia andZimbabwe, could have a major positiveimpact to these countries’ health deliverysystems.

Indeed, paradoxically, it is at the presentconjuncture – when the health sector is fac-ing cuts of unprecedented scope – that thebenefits to the NHS and the UK of a care-fully planned circular migration model aremost apparent. Some projections predictNHS job cuts of 10 per cent of the totalworkforce, amounting to perhaps 6,500nursing positions (West 2009). The spon-sorship of the return migration of qualifiedhealth workers could draw on funding

streams beyond the NHS; salary costs insending countries are typically a fraction ofthose in the UK, in pound-denominatedterms, and return contracts of limited dura-tion could address future local staffingshortages in a manner that is more fine-tuned than the proposed elimination offull-time positions. At the same time, thenegative effects of other budgetary propos-als – including increased numbers of shifts,reductions to training budgets, extendingwaiting times, and the hastening of earlyretirement of experienced professionals –could be minimised or avoided.

Indeed, several proposed longer-termchanges in health worker retraining and

reorganisation, such as shifts to more com-munity care, to an all-graduate nursingworkforce, and to increased staffing of assis-tant practitioners, all require improving themorale and active engagement of the cur-rent workforce. Arbitrary and top-downcuts are precisely the wrong way to goabout achieving these ends. More basically,a large body of evidence points to thedirect links between well qualified andappropriately situated medical personnel,and improved patient, nurse and financialoutcomes. Thus, promotion of circularmigration in the short term can assist inachieving longer-term goals of improvinghealth worker morale and health outcomesin the UK (as well as in the sending coun-tries).

Other incentives for UK policymakersinclude strengthening the ties with thesekey sending countries in order to maintainand increase the UK’s global competitive-ness in recruiting and retaining healthworkers, while at the same time increasingstaffing in home countries over the longerterm. What currently threatens to becomea vicious cycle of boom-bust recruitmentcould thereby be transformed into a virtu-ous one.

Dr Andrew Lawrence is lecturer in AfricanPolitics at the Centre of African Studies,University of Edinburgh.

Buchan J (2002) ‘International recruitment of nurses:United Kingdom case study’, WHO research report

Eastwood J et al (2005) ‘Loss of health professionals fromsub-Saharan Africa: the pivotal role of the UK’. TheLancet, 365, 9474, 28 May–3 June: 1893-1900

European Commission (2007) ‘Circular migration andmobility partnerships between the European Unionand third countries’, MEMO/07/197, 16 May

Finch T and Mulley S (2009) ‘Navigating the migrationdebate out of a dangerous cul-de-sac’, Public PolicyResearch, 16, 2: 120-126

IWP (2009) Corporate website:www.internationalworkpermits.com/uk-hsmp.html

Mesquita J and Gordon M (2005) The international migra-tion of health workers: A Human Rights Analysis,London: MedAct

Mills E et al (2008) ‘Should active recruitment of healthworkers from sub-Saharan Africa be viewed as acrime?’ The Lancet, 371, 9613, 23 February: 687

West D (2009) ‘NHS could cut 6,500 nurse jobs as reces-sion bites’, Nursing Times online, 2 September

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Arbitrary�and�top-down�cuts�are�precisely�the�wrongway�to�go�about�achievingthese�ends