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Is care-worker migration really a
form of exploitation?
Mark Radford
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Exploitation?
1. Picture of the global health workforce.
2. The source countries, with particular reference to Sub-
Saharan Africa
3. The care workers, factors influencing the migration of Indian
nurses. Two local case studies.
4. The United Kingdom, poacher turned gamekeeper?
5. Conclusion. To what extent is this exploitation.
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An Ageing Society, Migrant Care Workers in Demand
The developed world is increasingly heavily reliant on migrants to providecare in residential homes and clients own homes.
In social care this covers formal and informal employment, including domestic
service, live in care workers, and working for home care agencies withincare homes
UK has a long history of seeking staff by drawing on relationships withCommonwealth countries. Countries such as the Philippines and Indiaencourage their citizens to work abroad.
The EU generally has been employing labour from the former sovietinfluenced states. There is some evidence this is declining as the recessionbites.
Source: Cangiano, Shutes, Spencer and Leeson 2009
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Source: Giovanni Lamura 2009
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Source: James Buchan and Julie Sochalski 2004
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Nurse Availability Data Selected SSA Countries
Adapted from WHO World health Report cited in Dovolo 2007
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Migration Push Pull Motivating Factors
in Six SSA Countries
Source: Awases et al 2004 cited in Dovolo 2007
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Impact of Migration on SSA
Health Service Delivery
Staff shortages mean systems cannot deliver critical services
Loss of staff with key skills
Loss of professionals contribution to the economy
Encourage development of private nurse training schools
Economic Effects
Loss of state investment in training of leavers
Loss to GDP
Increases in remittances
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Migration from the care worker perspective.
The international migration of Indian nurses.
In past Indian nurses have generally migrated to Middle East.
New opportunities in West have arisen in recent years.
Market pull is likely to continue
Population of richer countries is ageing whilst in poor
countries the share of young people remains high
Improvement in medical interventions which prolong life
generates a demand for trained nurses
Despite increasing nursing enrolment in rich countries women
who would have trained as nurse are opting for more
prestigious work
Adapted from Thomas 2006
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Chi-squared values showing the relationship between the
intention to migrate and selected respondent attributes (n = 448)
Source: Thomas 2006
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Case Study : Beena Joseph
Beena with husband Vinny and children
Rosemary (10) and Richard (6)
Age: 40
Religion: Roman Catholic
Mother Tongue: Malayalam
Home State: Kerala
Nursing Qualifications:
Registered Nurse and
Midwife in India
Experience: Worked in govt
hospital in India for 8 years.Moved to Saudi Arabia for 4
years, worked on medical
wards. Has worked in
private care homes in UK
since 2004.
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Case Study: Beena JosephPush and Pull Factors
bringing Beena to UK:
Income higher than
government hospital in
India. Joint income in UK
lower than Saudi Arabia
but lifestyle much better.I like the culture and
freedom here
Little opportunity to
practise RC faith in Saudi
and employment meant
Beena and Vinny lived
apart.
Facilities in hospital
comparable in all three
countries.
Stick Factors: Good work prospects. Children
anglicised and happy at school. Vinny would like
to stay in England for good, Beena misses her
wider family.
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Case Study:
Silvy Jacob
Age : 40
Religion: Roman Catholic
Mother tongue: Malayalam
State: Kerala
Nursing Qualifications: Registered
Nurse and Midwife in India.
Experience: Worked in private
hospital in India. Moved to UK in
2004 where she is Nurse in Chargeat a private care home.
Silvy at work whilst Cyril has tea
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Case Study: Silvy Jacob
Push/Pull Factors influencingSilvys decision to move to UK.
Poor pay, little promotion
prospect, the hospital I worked
in was not well maintained and
not always very well equipped.
Long waiting list to work ingovernment hospital, I had to
register at an employment
exchange
Stick Factors: Happy in job, good
working conditions and supportfrom English NMC. However,
intend to move back to India
sometime in next 10years with
husband Jose. Children Minna
(14) and Sona (7) may choose to
stay.
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The United Kingdom An exploiter?
Country has been prominent in international labour markets because ofhome shortages
Ageing population
Insufficient recruitment from home
Improved technology and types of treatment
UK government committed to expanding NHS 20,000 more nurses by2004
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Migrant Care Workers The Issues
Vacancies are high care work appears unattractive to local
potential workers
Care Agencies accused of mistreating migrant care workers
Managers lack training to deal with issues of discriminationand harassment
Migrant workers unlikely to be members of trades unions
Live in migrant care workers particularly vulnerable because
status may be unclear. Lack contracts and conditions Integration into communities, language courses,. Introduction
to local customs, colloquialisms and social expectations.
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Oxfams -Who Cares?
This report was published on 2nd December 2009. It contains
evidence of abusive practices among some agencies who
supply workers from abroad.
The report states The increasing use of migrant workers has notbeen matched by a recognition of the experiences of migrant
care workers and the ways in which employers and agencies
will exploit their vulnerabilities in order to keep costs down
and compete with other social care providers.
Oxfam calls on government to extend the Gangmasters LicensingAuthority but refuses to name the offending agencies
Source: guardian.co.uk
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The United Kingdom stands out as a country where active
international recruitment of nurses and other health
professionals , was an explicit national-level governmentpolicy response to the need to increase staffing levels in a
public sector, government funded health care system.
James Buchan 2007
Admissions to the UK Nurse Register from European Union and
Other Countries 1993/2005: J Buchan 2007
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Does a code make a difference?
The Department of Health in England
introduced a Code of Practice for
international recruitment for National
Health Service Employers in 2001
The code required National Health
Service employers not to actively recruit
from low income countries, unless there
was government to government
agreement. The code was updated in
2004.
The level of international recruitment
has dropped significantly since early
2006. Regulatory and education
changes in the UK in recent years have
also contributed to this fall.
Adapted from: Buchan 2009
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The potential to assess the English code is limited by available databases. For example,
there is not a registration system for all care workers. There is evidence the numbers
of nurses from list countries entering the country is falling. It is unclear at present to
what extent this is due to the code and to what extent it is due to a fall in demand
although it is likely both are playing a part.
Nurses: new registrants in the United Kingdom, other developed
countries, list-exempt countries and list countries, 1998 -2006 Cited in
Buchan 2009 Source: Nurses and Midwives Council, United Kingdom
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Numbers
Numbers of Zambian RNs requesting verifications from the
GNC for the top eight destination countries (1991 -2005)
Source: Hamada 2009
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An example for others to follow?
There are now numerous codes of practice following the English
initiative. Their effectiveness is yet to be demonstrated (WHO
2006)
Codes assume a permanent loss to the source country.
Temporary loss can lead to a net gain.
It may be more suited to the UK than elsewhere where there
is one large public sector employer
The code has a good level of recognition in the NHS but would
benefit from better dissemination in low income countries
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Conclusion-Exploitation?
With an ageing society the demand for care workers will increase. Care workerswithout qualifications often work in a poorly regulated environment. This provides
an opportunity for exploitation by a minority of unscrupulous employers.
Some evidence indicates unfair treatment of migrant workers in the UK amounting to
exploitation. It is likely the same is happening in other EC and western countries.
A comprehensive approach is required to tackle both the long term care of the elderly
in ageing societies and migrant challenges at an international level. The work of
the WHO is crucial to this.
In order to minimise exploitation the legal position of unqualified migrant workersshould be reviewed. Data are limited especially in source countries. Protocols have
been developed in recipient countries but these mainly apply to registered health
workers.
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Conclusion Exploitation?
.
Evidence of exploitation of trained health workers is limited. Benefits sometimes
accrue to source country, destination country and to the nurse themselves. The
case study of Indian nurses in England supports this.
In developing nations, particularly those in Sub Saharan Africa, migration has had adetrimental impact on existing hugely overstretched health care systems. These
losses can be mitigated to some extent by returning skilled workers and
remittances from those abroad. In India the disparity in resources between state
and privately run hospitals has contributed to nurse migration.
Freedom of workers to move from place to place in order to work is a desirableobjective in a free society but any abuses that result must be addressed.
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Bibliography
Department of Health 2004 Code of Practice for the International Recruitment of Healthcare Professionals
Wanless D 2001 Securing Our Future Health: Taking a Long Term View. HM Treasury London
Kingma M 2007 Nurses on the Move: A Global Overview Health Services Research 42:3 Part II
Cangiano, Shutes, Spencer and Leeson: 2009 Migrant care workers in ageing societies University of Oxford
Lamura G 2009 Opportunities and challenges of migrant care workers on the elder care sector. Department of
Gerontology University of Ancona Italy
Buchan J 2007 International Recruitment of Nurses: Policy and Practice in the United Kingdom Health ServicesResearch 42: 3 Part II
WHO 2006 The World Health Report 2006 - Working Together for Health Geneva World Health Organisation
Buchan J & Sochalski J 2004 The Migration of nurses: trends and policies Bulletin of the World HealthOrganization 82,8 587-594
Gentleman A 2009 Care agencies accused of exploiting migrant care workers www,guardian.co.uk
Thomas P 2006 The international migration of Indian nurses International Nursing Review 53, 277-283
Kingma M 2001 Nursing migration: global treasure hunt or disaster-in-the-making? Nursing Inquiry 2001: 8(4)205-212
Dovlo D 2007 Migration of Nurses from Sub-Saharan Africa: A review of Issues and Challenges Health ServicesResearch 42:3 Part II
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Bibliography
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