Which Medical Migrants Should be Prioritised?

The Merits of International Medical Graduates Compared to

International Students Qualified in Australia

Lesleyanne Hawthorne

Professor – International Health Workforce

Faculty of Medicine, Dentistry and Health Sciences

International Association of Medical Regulatory Authorities Conference 2014

11th International Conference on Medical Regulation

London (9-12 September 2014)

Growing Reliance on Medical Migration:

Australia (2001 & 2011) Compared to Canada (2001)

Occupation 2011 % Overseas-Born

In Australia

2001 % Overseas-Born

In Australia (compared to

Canada)

Engineering 62% 48% (50%) Computing 57% 48% (51%) Medicine 48% 46% (35%) Science 37% (36%) Commerce/ business 43% 36% (27%) Architecture 36% (49%) Accountancy 53% 36% (35%) Arts/ humanities 31% (24%) Nursing 29% 24% (23%) Education 24% 20% (15%) Source: 2001 and 2011 Census data analysis, Australia and Canada; The Impact of Economic Selection Policy on Labour Market Outcomes for Degree-Qualified Migrants in Canada and Australia, L Hawthorne, Institute for Research on Public Policy, Vol 14 No 5, 2008, Ottawa, 50pp

Transformation of Global Skilled Migration -

Demand for Migrant Health Professionals

1. Demographic contraction:

OECD and select other countries (eg Singapore, Japan)

2. Prioritisation of skilled migration:

Up to 68% of permanent intakes to Canada, Australia and New Zealand

3. 21st century mobility patterns: Transformed!

Hypermobility (eg India Gulf S Africa NZ Australia)

New directions (eg pan-Asian)

Scale of temporary flows

Individual agency (+ migration factored into career choice)

4. Medical migration pathways: Permanent versus temporary versus international student flows

Bilateral + multilateral agreements (EU, Trans-Tasman, NAFTA)

1. Bilateral/multilateral agreements (eg Trans-Tasman)

2. International students (study-migration pathway)

3. Temporary sponsored migrants

4. Permanent skilled migrants

5. Partners of skilled migrants

6. Family and Humanitarian category migrants

Government Construction of Medical Migration

Pathways - Australia

Pathway 1 -

Growth in Permanent Migration of International Medical Graduates

(2006-2011)

Field

2001-2005 Arrivals

2006-2011 Arrivals

Medicine 7,241 12,696

Nursing 8,584 19,746

Pharmacy 1,798 3,005 Physiotherapy 755 1,556

Dentistry 1,063 2,343

Top Sources for International Medical Graduates

Accepted by Australia: 2006-11 Permanent Migrants

Medicine = 12,696 new IMGs

India: 2,625

Sri Lanka/ Bangladesh: 2,022

UK/ Ireland: 1,579

North Africa + Middle East: 1,194

Canada/ USA: 719

China: 705

Malaysia: 634

South Africa: 632

Other Africa: 479

Philippines: 473

Pathway 1 - Issues

Challenges:

Training variability

Technological ‘fit’

Language and communication skills for clinical practice

Issue 1: Australian Medical Council assessment

Issue 2: English ability

Issue 3: Medical employment access

AMC Assessments: 2012 + 2013 Annual

Reports

Assessment type (2012):

7,412 initial document verifications

2,881 written examination (MCQ)

1,941 clinical examination (plus 437 clinical re-test)

59 workplace-based assessment candidates

Competent Authority assessment outcomes (2013): Countries of training = 56

CA type:

GMCUK (652), PLAB (85), MCI (84), MCC (68), USMLE (28),

NZREX (7)

CA outcomes (1,123 applications):

Advanced Standing issued (1,068)

AMC Certificate issued (630)

Impact of English Ability on IMG Registration (Australia)

Standard required: Set by relevant regulatory bodies

Data: Occupational English Test data (2005-2011)

Nurses (17%) Pharmacists (38%), Doctors (52%), Dentists (62%)

53%

20%

40% 38% 39%

46%

37%

43%

19%

47%

34%

28% 32%

34%

52%

17%

62%

32%

38% 40% 41%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

Ca

nd

ida

te p

as

s r

ate

(%

)

2005

2010

2011

Impact of Source Country/ Region on IMGs’ Employment in

Medicine in Australia (First 5 Years) – Permanent Residents Only

2011 Census:

Overall: 57% of 2006-11 arrivals employed in medicine within 5 years

Most likely to practice: South Africa (83%), Malaysia (75%), UK/Ireland (74%), SE Europe (61%), India (61%), West Europe (59%), Singapore (56%)

Modest performers: Philippines (46%), South/ Central America (42%)

Poor outcomes: East Europe (27%), Vietnam (12%), China (8%), Indonesia (4%)

Unemployed or ‘Not in the labourforce’ within 5 years: China = 43%, Japan/ South Korea = 44%, Vietnam = 65%, Indonesia = 65%

Looming pressures – eg ASEAN (health sector focus)

Bilateral agreements – eg Japan-Indonesia (nursing case study)

Comparative Employment Outcomes for IMGs in Canada:

First 5 Years by Source Countries/ Regions (2001)

Top 1996-2001 arrivals (all immigration categories): 1. China (3,587) – 4% employed in medicine in first 5 years

2. S+C Asia (3,052) – 12%

3. E Europe (2,137) – 8%

4. Other Middle East/ North Africa (1,714) – 15%

5. Philippines (1,612) – 3%

6. India (1,604) – 19%

The latest Canadian IMG arrivals by main source country 2006-12

(practising):

Pakistan (+66%)

Egypt (+36%)

US (+31%)

South Africa (+25%)

India (+22%)

Decline = UK/ Scotland (-16%)

Pathway 2 - Recent Dominance of

Temporary Resident IMGs

Challenges associated with temporary sponsored flows:

Hyper-mobility - Length of stay?

Immediacy of employment?

Clinical purpose/ location

Availability of supervision?

Willingness to invest in full registration

CASE STUDY: ‘Area of need’ appointments (up to 4 years)

Coercive visa powers (compared to Canada)

Growth in Australian Employer Sponsorship All Fields

(‘Areas of Need’): 2003-04 to 2011-12

Attractions of the Temporary IMG Pathway:

Facilitating Labour Flows + Employment

Attraction to Employers/ Sponsors: Private and Public, Regions

Attraction to Migrants

Multiple agents empowered to facilitate entry

Speed of selection/ entry

Capacity to mandate location and maintain public sector workforce supply (condition of visa)

Scope to secure limited/conditional registration

Immediate employment

Immediate earnings

Scope for transition to two-step migration (after trial) Lower threshold for selection (eg 70 not 120 points) No pre-defined category limits (organic response to labour market demand)

Pathway 1 (Permanent IMGs) Compared to Pathway 2

(Temporary IMGs): June 2010-2013 Arrivals

Types:

PERMANENT SKILLED 2010-11 2011-12 2012-13 Total

Nursing 1374 1174 1406 3954

Medicine 505 1036 1289 2830

Pharmacy 157 223 242 622

Dentistry 113 170 206 489

Physiotherapy 95 80 80 255

GSM Total (All Fields) 2244 2683 3223 8150

TEMPORARY SKILLED 2010-11 2011-12 2012-13 Total

Nursing 2275 3195 2940 8410

Medicine 2930 3320 2865 9115

Pharmacy 25 15 20 60

Dentistry 160 170 160 490

Physiotherapy 100 110 120 330

457 Visa Total (All Fields) 6460 8090 7560 22110

GRAND TOTAL (All Fields) 8704 10773 10783 30,260

Top Sources for Temporary Sponsored Migrants:

June 2013-14

Medicine = Around 4,000-5,000 IMGs sponsored/ resident a year -

Top source countries:

UK/ Ireland: 1,020

India: 1,000

Philippines: 730

Ireland: 490

Zimbabwe: 60

China: 50

South Africa: 40

Canada: 40

US: 40

South Korea: 30

Australian Medical Council:

Competent Authority Pathway

1. PLAB Professional and Linguistic Assessments Board

examination of the United Kingdom

2. MCC Medical Council of Canada Licensing Examination

3. USMLE United States Medical Licensing Examination

4. NZREX New Zealand Registration Examination

5. GMCUK General Medical Council–accredited medical

school in the United Kingdom

6. MCI Medical Council of Ireland–accredited medical

school in Ireland

Alternative Registration Pathways for IMGs 2008+:

Recruitment Impact of the Competent Authority Pathway

Specialists

? X

Fast

Me

diu

m

Slo

w

Attraction to IMGs Resident in NZ:

IMG Retention in Medicine (Within 5 Years)

Migration in NZ = ‘demographic survival’

1955-2004: 2.3 million migrants leads to net population gain of just

208,000 people

Dependence on migrant health professionals: Highest in the OECD

2005-09: 7,102 work permits issued to IMGs + 1,612 permanent

skilled migrants

2009: 323 new domestic graduates + 1,141 IMGs registered

Top sources: England, S Africa, Scotland, Australia, India, US, Sri

Lanka, Ireland, Germany + Iraq

Retention by 2008: Just 50% retained a year after initial registration +

31% for 3 years

Retention by source country + training system:

<50% from S Africa for 5 years

<30% from UK x 2 years

<30% from US/Canada IMGs x 1 year

Highest retention rate = Asia-trained IMGs (50% resident @7 years)

2012: 41% of medical workforce = IMGs (38% in 2007)

AMC MCQ + Clinical Pass Rates on 1- 4 Attempts:

By Select Candidate Source Country (2013)

MCQ Exam (No = 2,885)

1. Sri Lanka: 78%

2. Singapore: 75%

3. Myanmar: 69%

4. Malaysia: 67%

5. Germany: 66%

6. South Africa: 63%

7. Iran: 62%

8. Pakistan: 57%

9. India: 54%

10. Bangladesh: 52%

11. Egypt: 45%

12. China: 42%

13. Russia: 41%

14. Philippines: 33%

Average: 55%

Clinical Exam (No = 2252)

1. Germany: 82%

2. Sri Lanka: 54%

3. South Africa: 53%

4. Singapore (no candidates)

5. Malaysia: 50%

6. Iran: 47%

7. Myanmar: 47%

8. Pakistan: 46%

9. China: 46%

10. Egypt: 42%

11. India: 40%

12. Russia: 37%

13. Bangladesh: 35%

14. Philippines: 28%

Average: 43%

Compared to AMC Clinical Examination Outcomes:

Top 10 Countries of Training, 2004-2010

Top 10 Countries of Training (Number)

% Pass % Fail % Re-Test

1. India (1,823) 52 29 19

2. Bangladesh (799) 42 38 20

3. Pakistan (665) 48 31 21

4. Sri Lanka (660) 58 22 20

5. China (594) 58 23 19

6. Iran (481) 56 27 17

7. Philippines (437) 34 46 20

8. Myanmar (374) 47 31 22

9. Iraq (333) 52 29 19

10. Egypt (277) 52 29 19

Other countries (2,646) 58 26 16

Total candidates (9,089)

53

29

19

Source: Data supplied to Health Workforce Australia by the Australian Medical Council (June 2011).

BUT – Australian Retention of Temporary IMGs?

Health Professional Emigration Rates: 15,317 Australian + Migrant

Health Professionals Emigrate (2004-05 to 2009-10)

Australian: 48%

Overseas-born: 52% - NZ (14%), UK (11%), China (4%), HK (3%)...

Key issue: Hyper-mobility + regional/national retention

Source: DIAC Emigration flows data (2011)

State of Previous Residence 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10

No. No. No. No. No. No.

New South Wales 855 878 906 919 1000 991

Victoria 485 589 575 552 576 660

Queensland 428 496 516 572 557 640

South Australia 109 148 135 156 140 158

Western Australia 252 284 293 297 319 336

Tasmania 25 31 49 40 40 31

Northern Territory 22 23 14 9 18 22

Australian Capital Territory 27 31 24 19 28 37

Total departures of Health Professionals(a)2203 2480 2516 2564 2679 2875

Total departures 62 606 67 853 72 103 76 923 81 018 86 277

(a) Includes departures from 'Other Territories'

Scale of Regional Workforce IMG Retention:

Supply in ‘Areas of Need’ Versus Retention?

Securing regional medical supply:

Visa status, Medicare billing rights, definitions of regions of shortage?

Dependence (select states):

Victoria (RWAV):

– 1,209 GP’s working in rural or remote areas

– 2010: 36% = IMG’s (RWAV)

Western Australia (Rural Health West):

– 2007: 52% of rural and remote GP’s = IMG’s

– 2010: 53% (double the level of reliance in 2002)

Queensland (Health Workforce Queensland):

– 2010: 46% of rural and remote GP’s = IMG’s

– 13% on 457 visas (conditionally registered)

BUT - Registration status? Conditional %? Risk of ‘two-tier’ medical care?

Access to bridging courses/ exam preparation?

Threat of securing full registration?

Long-term location?

Pathway 3 - International Students as a Workforce

Resource: The ‘Study-Migration’ Pathway

Compared to IMGs – self-funded to meet local requirements:

1. Fully recognised qualifications

2. English testing exemption (IELTS 7 on enrolment)

3. Youth + future productivity (aged 24 years)

4. Local experience

5. Acculturation

Field 1996 2000 2002 2004 2008 2009

Dental science 98 124 155 227 341 387

Medicine 963 1117 1287 1505 2665 2772

Nursing (basic) 762 839 790 1623 5451 6124

Nursing (post-basic) 545 2336 3591 3109 2631 2566

Physiotherapy 79 173 197 239 392 365

International Student Location by 2008:

Higher Education Enrolments by Host Country

(All Fields)

Top 12 Global Destination Countries (2007-2008)

International Students Enrolled in Higher/ Vocational Education

1. US 623,805 (2008)

2. Australia 389,373 (2008)

3. UK 389,330 (2008)

4. France 260,596 (2008)

5. Germany 246,369 (2007)

6. China 223,499 (2008)

7. Japan 123,829 (2008)

8. Canada 113,996 (2007)

9. Singapore 86,000 (2007)

10. Malaysia 72,000 (2008)

11. South Korea 63,952 (2008)

12. New Zealand 39,942 (2007)

Source: Compiled from data provided in International Student Mobility: Status Report 2009, V Lasanowski, The Observatory on Borderless Higher Education, UK, June 2009

Potential Skilled Migration Applicant Pool:

515,853 International Students Enrolled in 2012

(Compared to 630,000 in 2010, All Fields)

Nationality 2012 Enrolments

%

of Total

Growth

on 2011

China (38% migrate by 2005) 149,758 29% -6%

India (66% migrate by 2005) 54,396 11% -25%

Republic of Korea 27,719 5% -7%

Vietnam 22,551 4% -4%

Malaysia 21,587 4% -5%

Thailand 20,240 4% -6%

Indonesia 17,514 3% -2%

Brazil 15,092 3% -1%

Nepal 14,074 3% -20%

Pakistan 11,298 2% +18%

Other nationalities 161,624 31% -2%

TOTAL 515,853 100% -7%

Australian Employer Preferred Place of Selection –

Facilitating Two-Step Migration (2011-12, All Fields)

Study-Migration Pathway in Medicine:

Place of Temporary Medical Migrant Selection (June

2013-June 2014)

On-shore:

Medicine: 35%

Clinical experience + specialist qualifications often sought

Nursing: 62%

Dentistry: 66%

Pharmacy: 100%

Physiotherapy: 75%

Australian Outcomes from the ‘Study-Migration’

Pathway: Medical & Health Graduates (2007-11)

Study: ‘Employer Response to the Study-Migration Pathway: The Australian Evidence 2007-2011’, L Hawthorne & A To (2013

review) Highly Skilled Migration: Policies, Processes and Politics, Special Issue, International Migration (Geneva)

Graduate Destination Survey data 2007-2011: International students: 80,000

Domestic students: 372,000

11 fields:

Sustained demand: Medicine, dentistry, nursing, pharmacy,

physiotherapy

Over-supply: IT, accounting, business & commerce

Highly variable demand: Engineering

Modest demand: Education, law

Employment outcomes @ 4 months: Compared by field, qualification

level, language background, source country, wage

Outcomes by Field 4 Months After Graduation in

Health – 2011 National Data

Employment rates -

Medicine:

98.8 per cent of international students employed full-time,

compared to 99.7 per cent of domestic graduates

Dentistry:

95.5 per cent compared to 93.5 per cent of domestic graduates

Pharmacy:

96.1 per cent compared to 97.6 per cent

Nursing (diploma to degree upgrade courses):

71.4 per cent compared to 91.7 per cent (additional 17% of

international students working part-time)

Former International Students: Full-Time Employment Rates 6

Months After Completing Australian Degrees by Field Compared to

Domestic Students (2007-11)

Qualification Field Australian Graduates

(Sample = 371,000)

International Students

(Sample = 79,000)

Accounting 83% 35%

Business 76% 40%

IT 78% 42%

Engineering 86% 44%

Medicine 100% 99%

Dentistry 94% 96%

Pharmacy 98% 96%

Physiotherapy 94% 67%

Nursing 92% 71%

Potential Value of the Study-Migration Pathway:

‘Designer Immigrants’?

Attributes: Young

Self-funded education

Length of future productivity

Host country language skills

Domestic qualifications

Acculturation

Australian case study:

1999: Immediate eligibility to migrate (supported by bonus points)

2005: 66% of Indian students and 38% of Chinese students

migrate on course completion

2007-11: 78% of international medical students plan to migrate

2011: 99% employed full-time year after graduation; wage parity to

Australians in PGY1

Issue: Future access to internship places? (Pre-requisite for PR

status)

Reprise by Contrast: IMGs’ Employment Rates in Medicine in

Australia (First 5 Years) – Permanent Residents

2011 Census:

Overall: 57% of 2006-11 arrivals employed in medicine within 5 years

Most likely to practice: South Africa (83%), Malaysia (75%), UK/Ireland (74%), SE Europe (61%), India (61%), West Europe (59%), Singapore (56%)

Modest performers: Philippines (46%), South/ Central America (42%)

Poor outcomes: East Europe (27%), Vietnam (12%), China (8%), Indonesia (4%)

Unemployed or ‘Not in the labourforce’ within 5 years: China = 43%, Japan/ South Korea = 44%, Vietnam = 65%, Indonesia = 65%

AND AMC MCQ + Clinical Pass Rates on 1- 4 Attempts:

By Select Candidate Source Country (2013)

MCQ Exam

1. South Africa (17/27)

2. Singapore (3/4)

3. Malaysia (31/46)

4. Germany (20/30)

5. Bangladesh (110/210)

6. China (50/118)

7. Egypt (49/109)

8. India (235/432)

9. Iran (133/214)

10. Myanmar (96/139)

11. Pakistan (174/307)

12. Sri Lanka (199/255)

13. Russia (40/98)

14. Philippines (52/157)

Average (1598/2885)

Clinical Exam

1. South Africa (20/38)

2. Singapore (-)

3. Malaysia (17/34)

4. Germany (18/22)

5. Bangladesh (57/161)

6. China (39/85)

7. Egypt (27/65)

8. India (179/449)

9. Iran (63/133)

10. Myanmar (71/150)

11. Pakistan (109/239)

12. Sri Lanka (98/181)

13. Russia (23/62)

14. Philippines (38/135)

Average (970/2252)

Exit Survey – 78% of International Students Remain in

Australia: Location of Internships Accepted

Actual Internship Location

International Students

N %

VIC 190 35%

Overseas 120 22%

NSW 93 17%

QLD 76 14%

SA 48 9%

WA 8 1%

ACT 7 1%

NT 3 1%

TAS 1 0%

Total 546 100%

The ‘Looming War for Skills’: Impact of Demographic

Contraction on Demand for ‘the Best’ Medical

Migrants

Traditional population structure Emerging population structure