Mobility of health professionals Between the India and Selected EU member states: A Policy Dialogue

Transcription

1 Mobility of health professionals Between the India and Selected EU member states: A Policy Dialogue 26 July 2013 India Habitat Center, New Delhi

2 CONTENTS Keynote Address... 1 Session 1: International Frameworks on Labour Migration... 5 International Standards (Protection) and the Multilateral Framework on Migration... 5 WHO Code of Practice on the international recruitment of health personnel... 6 Monitoring of the implementation of the WHO Global Code of Practice on the international recruitment of health personnel... 7 Session 2: Assessment of Services to Professional and Skilled Health Migrants -- India and the Philippines... 9 Assessment of services for skilled migrants from India... 9 Assessment of services for skilled migrants from the Philippines Session 3: The Assessment of Working Conditions of Foreign-trained Health Professionals in Europe Investigating the working conditions of Filipino and Indian-born nurses in the United Kingdom International mobility of nurses from Kerala to the EU: prospects and challenges Session 4: The Effects of the Migration of Health Professionals on the Health Sector of the United Kingdom Assessment of the impact of migration of health professionals on the labour market and health sector performance in destination countries Round Table Discussions Policy Implications and Recommendations Closing of the Policy Dialogue... 24

3 The objective of this expert round-table discussion held in New Delhi on Friday 26th July 2013 was to validate the policy researches commissioned by the International Labour Organization s (ILO) Decent Work Across Borders Project (DWAB). The participants shared their opinions on the relevance in practical and policy terms and implications of the research findings, in order to inform the final version of the ILO DWAB s collaborators. Each of the main researchers presented details of their researches and the policy implications that could be extracted from their findings. This was followed by comments and observations by the discussants, followed by an open discussion. A lively, honest and engaging debate produced numerous issues. The details of each of the sessions are given below. Keynote Address Ms Catherine Vaillancourt-Laflamme, Chief Technical Advisor of ILO DWAB, Manila, welcomed the delegates and talked about professional mobility being a complex issue. The Right to Mobility, Right to Health and the Right to Labour were embedded within the Decent Work Agenda. She said this was an opportunity to share two different models: that of India and the Philippines. She opened the discussion by saying that there was a need to share opinions and contribute to the debate in order to enrich it. Ms Tine Staermose, ILO Director for South Asia and Country Office for India, invited Mr TK Manoj Kumar, Joint Secretary-Diaspora Services, Ministry of Overseas Indian Affairs, and CEO of the India Centre of Migration to share his perspective. Mr Kumar found it a privilege and a pleasure to be at this meeting and after welcoming everyone, especially the titans of research, volunteered to share some remarks on the issue: The Government of India s official stand was that it neither stops nor supports migration. However, the Government supports safe and legal migration, and migration with dignity. The e-migrate Project was a comprehensive database initiated to understand which migrants are going in and out of the country. A new immigration Bill on the existing situation was on the anvil. The Government promotes skilling through the National Skill Development Agency. A lot of young people were expected to migrate from the country, and skill development would prepare the migrant departure. Therefore the mandate of the Ministry of Overseas Affairs was to train five million people by Circular migration was a very sensitive topic, and he felt it was a good thing. However, migrants should not be forced to return home after greatly contributing to their destination country. Strong rehabilitation measures were recommended when migrants returned home, so they did not find themselves strangers in their own land. The need for strong evidence was very evident; therefore this Project was of enormous value and importance. 1 P a g e

4 Ms Silvia Costantini, First Counsellor-Political Affairs, Delegation of the European Union to India, emphasized the importance of this pilot Project to better understand circular migration of health-care professionals, especially nurses: According to her, the biggest challenge for health care in the European Union (EU) was the steady increase of life expectancy. Therefore, the need for geriatric care has increased. Less advanced European states were finding it difficult to retain health-care professionals vis-à-vis the more developed European states. With regard to the issue of brain drain, she emphasised that the EU does not underestimate the fact that brain drain can be damaging. The migrant source economy was under strain, which could affect systems. However, brain drain was a consequence of people moving in order to better their career opportunities. There needs to be a win-win-win situation for all three stakeholders involved: the receiving country, the source country through remittances, and the migrants themselves through enhanced employment opportunities. Therefore, there is a need to turn brain drain into brain gain, or putting human capital to better use. Ms Costantini mentioned the EU s focus on raising the attractiveness of migrants, as part of Europe s 20:20 strategy, which aimed to build political momentum in favour of migrants. She described the blue card as a tool that allows health professionals to enter/leave a country; and which ensured that the skills and training the health professional acquired was used to the advantage of both the source and destination country. She highlighted the importance of returning workers motivating others to go abroad, which benefitted the educational system. The Philippines was cited as an example for having potential for high growth, and therefore brain gain. She reiterated the fact that the remittances sent home by the high-skilled health professional was an important source of income for the source country. Ms Costantini reiterated that ethical recruitment was a core value of EU, and skill upgrading was very important for migrant health workers. She said the EU supports the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel. Ms Costantini also spoke about the need to understand the situation in both the host and destination countries, for which she too underlined the need for strong evidence. Since India is a major source of health migrants, she said there was a need for a comprehensive approach. In Asia, the EU has a long-term strategy with India, with which it had a structured bilateral dialogue last year that led to the setting up of a common agenda. As a result, the development of this Project and the knowledge created by it would prove invaluable. Dr Vishwas Mehta, Joint Secretary, Ministry of Health and Family Welfare: There are 540 million people under the age of 25 in India. This demographic dividend can either be an asset in terms of skilled, trained professionals, or a liability in terms of illiterate people. 2 P a g e

5 He said migration of health workers from India has been happening for decades, and recently nurses had joined that phenomenon. Migration of health workers will always happen, it cannot be stopped. Dr Mehta admitted that people will go abroad for brighter career opportunities. However, migration should be less exploitative and as hassle-free as possible. Not only should the migrants be happy and satisfied, but those receiving them should be, too. Dr Mehta mentioned that systems should be developed that are acceptable to both host and destination countries. For example, these could be in the form of some accreditation or exam. Presently, there is no working reciprocal arrangement with other countries. No doctor or nurse going abroad can work there without degrees. India has thousands of nursing colleges and schools. There are 1.5 million people registered as nurses, but he lamented the fact there are no live registers. There are no numbers available on how many people have gone abroad, and how many have retired. The case is similar with doctors, of whom 80,000 are registered with the Indian Medical Association. Doctor to citizen ration in India is 1:1,700, and he did not know how that gap could be bridged. He said expansion was needed, but then the quality would be affected. More doctors are required, but there were not enough faculties in the medical colleges. With regard to the allied health system, Dr Mehta said that another 1.6 million health professionals were required in the country; and there is an urgent need to standardize the nursing and allied health-care system. However, for a population of 1.2 billion, it is not an easy task. Ms Staermose: Ms Staermose began by thanking everyone for coming to engage on the important issue of international migration and health workers at the ILO in Delhi. International migration is not only a complex issue involving many countries; it also requires close collaboration between different governmental institutions, including key ministries. She appreciated the participation of organizations and people without whom this activity would not have been possible, in particular the Ministry of Labour and Employment, the Ministry of Overseas Indian Affairs, and the Ministry of Health and Family Welfare. She also thanked the EU for providing the funding to enable the ILO to mobilize and provide technical assistance to its key constituents in India, as well as in the other countries that are part of the DWAB Project. The main points of her address were: Across the world, the number of migrants crossing borders in search of employment and human security is expected to increase rapidly in the coming decades, due to the failure of globalization to provide jobs and economic opportunities. Ms Staermose stated that the ILO sees today s global challenge as forging the policies and the resources to better manage labour migration so that it contributes positively to the growth and development of both home and host societies, as well as to the wellbeing of the migrants themselves. In 2004, the International Labour Conference of the ILO adopted a Multilateral Framework on Labour Migration, which is part of a plan of action for migrant workers agreed by ILO constituents. The Framework is part of an ILO plan of action that aims to better manage 3 P a g e

6 labour migration, so that it contributes positively to the growth and development of both home and host societies, as well as to the welfare of the migrants themselves. The ILO established the earliest international standards on migration to ensure a fair deal for migrant workers, and to maximize gains for both sending and receiving countries and stakeholders. She further elaborated that labour migration occurs and persists because it offers substantial economic benefits to migrant workers and their families, as well as the countries of origin and destination. In terms of health professionals (nurses and doctors) who migrate to find employment, some of the known factors that pull this migration flow are that in many destination countries, the populations are ageing and the demand for elderly care is increasing. Together with better wages, working conditions and opportunities for professional development constitutes the key factors. In order to design the best policy response to these challenges, Ms Staermose emphasized that it is critical to collect and analyse data through research, in order to design efficient policy interventions for the benefit of all. A more detailed analysis of the opportunities and challenges of circular migration are needed in order to reap its benefits, especially for health professionals, and equally for the countries involved. Circular migration has recently been promoted as a triple win solution to migration. This concept has been widely used and promoted in particular by certain EU Member States and the EU itself. As stated by some of the more critical segments of the migration stakeholders, circular migration could be a way of filling gaps in the labour market without having to fully integrate those who only come for a limited period of time, or on a seasonal basis. According to Ms Staermose, sending countries such as India will benefit in terms of remittances. But more importantly, by taking a medium to long-term perspective, India will benefit from returning health professionals, who have gained international experience and exposure and received professional training, which will then benefit the medical environment including patients in India. In turn, this may address some of the quality issues in the health sector, but only if these health professionals return. Receiving countries such as those in the EU will be able to satisfy their need for skilled labour in the health professions. The ILO brings stakeholders together to design programmes and approaches so that migration can take place in a safe manner. The ILO strongly believes that migrants are less vulnerable when they are moving out of choice, and not out of necessity. This is done by engaging governments, employers and workers organizations, and professional organizations and recruitment agencies. The ILO supports, through technical assistance and upon request, the development of key policies in the world of work. In many countries, including in South Asia, the ILO has provided technical assistance to labour migration policies for specific professions. The decent work agenda of the ILO is at the very heart of their work. She further elaborated that the ILO is not only concerned about safe and regular migration, but through a strong rights-based approach that focus on fundamental rights and principles including the protection of workers in the process of labour migration. This is critical, if only for the fact the workers themselves are part and parcel of designing the best models, for the overall policy to be implementable and serve the purpose it is designed to serve. 4 P a g e

7 Ms Staermose ended by saying that another key dimension of how the ILO works, both nationally and globally, is through the promotion of dialogue; not only social dialogue for collective bargaining of wages and working conditions, but also dialogue to promote the creation of synergies between different policy frameworks within a country. Session 1: International Frameworks on Labour Migration Facilitator: Ms Neetu Lamba, Programme Officer, ILO Delhi Mr Nilim Baruah, Regional Migration Specialist for Asia-Pacific, ILO International Standards (Protection) and the Multilateral Framework on Migration Giving an idea of the scale of labour migration, Mr Baruah said that estimates of migrant workers by ILO for 2010 are million, out of which a little over 30 million (or almost 30 per cent) were in Asia. However, these numbers do not fully reflect the significance of the migrant workforce in many countries and economic sectors. Women compose almost about 50 per cent of migrant stocks though this number differs from country to country. Economic growth, demographic changes, labour shortages and wage differentials among countries of origin and destination continue to drive labour migration in Asia. In addition to intra-regional flows, there were skilled labour flows to Organisation for Economic Co-operation and Development (OECD) countries. Higher wages in OECD countries --combined with selective migration policies that favour skilled migration of foreign workers -- attracted a large and growing skilled workforce, especially from India, China and the Philippines. The challenges in the countries of origin included information dissemination and skills development, and regulation of recruitment. The challenges in the countries of destination included admission policies (balancing different interests, regulation of recruitment, reducing irregular inflows, etc) and post admission policies (decent work for all, equal treatment between nationals and foreign workers, and extension of labour laws). He cited the Korean programme as an example that was good in terms of recruitment rights, but that there were problems with regard to the return of migrants, as conditions were not better on their return. With regard to the international legal framework, Mr Baruah explained that there were numerous international instruments that existed to provide standards for human rights. However, these instruments generally did not affect the state s sovereign right to control and regulate its borders. On Migration-specific conventions, Mr Baruah explained that ILO Conventions (No. 97 and No. 143) were the first international instruments for Migrant Workers (MWs). They put forward equal treatment between regular status migrants and nationals in employment and working conditions, and measures to address irregular migration. The international convention on the protection of the rights of all MWs and family members is the most comprehensive instrument on MWs and has a section on the rights of irregular MWs. Along with C143, it contains provisions intended to ensure that MWs enjoy a basic level of protection, whatever their status. Among other ILO 5 P a g e

8 Conventions particularly relevant for MWs includes C118: Equality of Treatment (Social Security); C157: Maintenance of Social Security Rights; and C181: Private Employment Agencies. On the ILO Multilateral Framework on Labour Migration, Mr Baruah stated that this is a global framework of non-binding principles, guidelines and good practices on a rights-based approach to labour migration. It is anchored on ILO conventions and standards, and based on tripartite negotiations and consensus of countries of origin and destination. Adopted in November 2005, it talks about nine areas consisting of 15 principles and corresponding guidelines. These nine areas or themes are: 1. Decent work -- access to freely chosen employment; recognition of fundamental rights at work; income to meet basic needs & responsibilities; adequate level of social protection; 2. Means for international cooperation in labour migration; 3. Global knowledge base; 4. Effective management of labour migration; 5. Protection of migrant workers; 6. Prevention and protection of abusive practices; 7. Promotion of orderly and equitable process of labour migration; 8. Promotion of social integration and inclusion; and 9. Contribution of labour migration to development. Mr Baruah said the guidelines for recruitment and placement included a standardized system of licensing or certification established in consultation with employers and workers organizations; respect of migrant workers fundamental principles and rights; and understandable and enforceable employment contracts. It also promoted sanctions to deter unethical practices, and fees and other charges for recruitment and placement not to be borne by migrant workers. With regard to migration and development, Mr Baruah shared that the guidelines included adopting policies to encourage circular and return migration and reintegration into the country of origin, including by promoting temporary labour migration schemes, and facilitating the transfer of capital, skills and technology by migrant workers, including through providing incentives to them. According to Mr Baruah, the Code needs to have a monitoring, rating and assessment mechanism. Mr Baruah ended by saying that promoting international cooperation and partnerships in managing international labour migration were essential for the protection and welfare of MWs, and also in curbing irregular migration and expanding legal migration. Dr Paul Francis, World Health Organization, New Delhi WHO Code of Practice on the international recruitment of health personnel Dr Francis began by saying that the WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted on May 2010, was developed to address crucial needs arising from both source and destination countries. The Code also went a little beyond recruitment and addressed a few systemic issues. 6 P a g e

9 The Code, according to Dr Paul, was voluntary. But member countries were strongly encouraged to use the Code as it served as a reference for ethical international recruitment, health workforce development, health systems sustainability and fair treatment of migrant health personnel. The Code provided a dynamic framework for global dialogue and international cooperation to address challenges associated with the international migration of health personnel. The Code also helped in information exchange on issues related to health personnel and health systems in the context of migration, and reporting on measures taken for its implementation. Ms Catherine Vaillancourt-Laflamme, ILO DWAB Monitoring of the implementation of the WHO Global Code of Practice on the international recruitment of health personnel Ms Vaillancourt-Laflamme said this was a collaboration of the Department of Health with the Department of Labor and Employment, in partnership with the ILO (Philippines), the WHO (Philippines and Western Pacific Regional Office) and multi-stakeholders. According to Ms Vaillancourt-Laflamme the WHO Code of Practice addresses health work-force migration, given the observed critical shortage in health personnel and weakened health systems experienced by some 57 source countries identified by the WHO. She said the Code was a tremendous tool for improving the ethical framework for migrant workers. The multi-stakeholder approach that was adopted included representatives from governments, employers (hospitals), trade unions, recruitment agencies and professional organizations. Ms Vaillancourt-Laflamme said that a wide audience was brought on board to monitor the implementation of the code to help make it a living document, and to get their perspective on how the Code helped, if at all. She also shared that from the perspective of the Philippines, as a sending country the stakeholders found the Code restrictive. This has created a demand for more knowledge in the Philippines. Ms Vaillancourt-Laflamme mentioned that after a broad-based and participatory process, the key recommendations on the monitoring of the implementation of the WHO Global Code included the: Monitoring instrument for sending and receiving countries should be differentiated. The questions need to be applicable to sending and receiving country respondents; and WHO monitoring instrument should include other elements to track implementation of the bilateral and multilateral agreements such as training, working conditions, grievance mechanism, skills recognition and responsibilities of recruitment agencies. Key recommendations: National level Local policies related to migration of health professionals needed to be harmonized, based on the requirements of the Global Code. 7 P a g e

10 The Code needed to be adapted to policies and programmes to ensure that ethical recruitment is adhered to by recruiters, which could serve as a basis to institutionalize negotiation mechanisms with foreign employers. Wide dissemination of the Code was required among migrant health workers, trade unions, employers and recruiters. Conduct policy and social dialogues among receiving and sending country stakeholders, including trade unions, on heath worker migration and the implementation of the WHO code. There was a need to create a formal feedback mechanism to obtain information from the health professionals going through the recruitment process to collect data on good and bad practices, so as to improve the monitoring of recruiters. The Code needed to be turned into something stakeholders could use to build knowledge. Ms Vaillancourt-Laflamme ended by saying that the biggest challenge that they faced in this entire exercise was the time constraint. Open Discussion Shiv Kumar, Co-Founding Director of Catalyst Management Services and Swasti Health Resource Centre, New Delhi, wanted to know the interplay in terms of the Code ownership, with regard to the central and state governments. What were the experiences from the Philippines? Dr Francis responded that with regard to the national vis-a-vis state codes, due to their legal and regulatory nature, they are addressed at the national level. The state governments were free to adapt it to suit their own specific needs. Dr Binod Khadria, Professor of Economics and Education, and Chairperson of Zakir Husain Centre for Educational Studies, Jawaharlal Nehru University, made a comment on a provision of the ILO Multilateral Framework on Labour Migration, according to which fees and other charges for recruitment and placement should not to be borne by migrant workers. But in reality this was not the case. He wanted to know whether these costs should be borne by the employee or employer. Mr Baruah clarified that recruitment costs generally did not include training cots; however as in the example of domestic workers from Cambodia who had to undergo training, the cost was borne by the workers themselves. Mr Parimal Sudhakar, a civil society representative, wanted to know what role civil society organizations could play in educating nurses, doctors on the Code? Could ethical recruitment be included in the nursing curriculum? Ms Vaillancourt-Laflamme responded, giving the example in the Philippines where doctors and nurses were extremely well-educated and went to university. So if there was a curriculum there named along the lines of challenges of nurses in a global world, it would be very useful. Ms Vaillancourt-Laflamme added that health mobility is a complex issue. There is a need to raise awareness of migrant health-sector workers about what they are likely to encounter in their destination country. However, health workers themselves also had a responsibility to seek information -- otherwise a passive category of migrants would be created. 8 P a g e

11 Ms Vaillancourt-Laflamme mentioned that there was a need to harmonize the multiplication of Codes for health-sector migrants to alleviate confusion, and there needed to be one standard to abide by. She also commented that there needed to be a definition for Ethical Recruitment for Agencies, and admitted that there needs to be better work done in this field. Session 2: Assessment of Services to Professional and Skilled Health Migrants -- India and the Philippines Facilitator: Ms Christiane Wiskow, Health Sector Specialist, ILO Geneva Dr Irudaya Rajan, Centre for Development Studies, Trivandrum Assessment of services for skilled migrants from India The objectives of Dr Rajan s study were to: 1) Map and assess the existing pre-orientation, pre-departure, and on-site and return services available to skilled health migrants; and 2) Identify gaps and provide policy recommendations for new services Dr Rajan explained that one reason why India s case was so special was that it ranked No. 1 in remittance-receiving countries with inflows reaching $69.8 billion for 2012 (World Bank, 2013). According to the International Migration Outlook (2013) it is the 4th largest source for immigrants to OECD countries. He explained that with the outflow of highly skilled health professionals from India, there is a risk that the country will not meet its health-related Millennium Development Goals. According to Dr Rajan, the research methodology included three case studies: the Ministry of Overseas Indian Affairs, which began in 2004; NORKA ROOTS, Government of Kerala, which started in 1996; and the Overseas Development and Employment Promotion Consultants (ODEPC), under the Department of Labour, which began in Professor Rajan traced the cycle of migration in the three case studies, which included the predeparture stage and on-site services. On Return services, Indian Nursing Council re-registers the nurses, recognizes their qualifications. Rehabilitation Programme for Return Migrants was also offered by NORKA. Findings from the field Pre-departure services: Recognition by the stakeholders that they were not providing many services for the skilled migrants. According to Dr Rajan, skilled migrants also felt that they could handle their migration and should be left on their own. Dr Rajan also suggested that pre-departure orientation or training should be offered for potential migrants. 9 P a g e

12 With regard to on-site services, he suggested that any dispute should fall within the jurisdiction of Indian courts. However, return services were not properly recognized and not organised according to the needs of the returnees. The Gaps include: On-site services; Lack of inter-ministerial collaborations; No mechanism in tracking migrants overseas; Poor redressal system; Return services; Absence of social security agreements with all destination countries; and Absence of services for returnee skilled migrants. The Gap analysis resulted to the following: Fragmented national policy frameworks and programmes; Absence of a strategic plan and services for skilled professionals; Lack of data on migrants; Pre-departure services; Lack of dissemination of information on services at grassroots level; Absence of stringent regulatory measures and benchmarks in recruitment processes; Limited operations and networks by government recruitment agency; and Lack of assessment of national and international job markets. Recommendations Administrative recommendations According to Dr Rajan, decentralized state level agencies should bridge the gap between policy and programmes. In this regard, he stated that the MOIA has already initiated to start a department of non-resident Indians (NRIs) at the state level. Two-level structure for skilled migrants should be established -- to fill the gaps in knowledge. All agencies, including the Ministry for External Affairs (MEA), the Ministry of Overseas Indian Affairs (MOIA), the Ministry of Home Affairs (MHA), the Ministry of Human Resource Development (MHRD) and the Ministry of Labour and Employment (MOLE) need to coordinate their efforts. Recruitment agencies and other players involved in student migration, such as tour agencies, should all be put under one ministry. Programme-related recommendations Dr Rajan explained that programmes for skilled migration should be done systematically and expanded overtime. There was a need for decentralization of activities through the Ministry of Panchayati Raj institutions. Unions can engage in providing information services to migrants. 10 P a g e

13 Professional organizations should engage in skills recognition. Recruitment agencies should provide more services and asked to carry out assessments of labour market needs. Information on national market for returnees. Dr Marilyn Lorenzo, University of the Philippines, College of Public Health Assessment of services for skilled migrants from the Philippines Dr Lorenzo began by stating that after seafarers, nurses were the second group from which maximum migration was observed. The Philippines implicitly supports emigration of its citizens who are able to work abroad and sustain the economy with remittances sent back home. Increased demand from developed countries that are in shortage of health professionals to care for their aging population has resulted in massive external migration. Filipino policy aims to meaningfully manage migration so that health professional migration benefits both destination countries as well as source countries like the Philippines. There is high interest in participating in international policy making to forge agreements towards ensuring mutually beneficial migration arrangements. Best practices are now in place for bilateral agreements between the Philippines and other countries needing nurses such as Canada and Bahrain. Specifically, the study aimed to: Review and confirm mapping of existing pre-orientation, pre-departure, and return services in the Philippines that are available to skilled migrants specifically for healthcare professionals; Describe services utilized by health professional migrants; Assess the effectiveness of existing services to health professional migrants; Identify gaps and needs for new services; Conduct a group consultation through round-table discussion regarding the results of the assessment of services for skilled migrants; Formulate draft recommendations based on the results of the data collection; and Develop relevant final recommendations to address identified needs and gaps. Key findings and conclusions Dr Lorenzo explained that the policies for the protection of the rights and welfare of Filipino migrant workers were developed as early as the 1960s. The explosion of services was observed around the year 2000 and up to 2010, when many non-government agencies -- including private recruiters -- began to complement government s work by providing migrant services. However, these new services were mostly provider driven and were not organized based on migrants felt needs. 11 P a g e

14 Results of the research showed that some government agencies had a crucial role to play in terms of the number of services provided. The private sector, specifically the recruitment agencies, provided very critical services, supplementary or complementary, to what the government agencies were already giving. Dr Lorenzo further explained that a number of agencies shared the responsibility of providing the same service. Therefore, there was a need to coordinate migrant services that are provided by a multiplicity of government and non-government agencies to prevent gaps and overlaps. Key recommendations Stakeholder recommendations Dr Lorenzo suggested that there was a need to streamline services and segregate health professional migrant workers from other migrant workers. In terms of recruitment services, placement fees needs to be abolished. To address the gap on skills and competencies of professional migrant workers, even before the health professionals decided to work in foreign countries, Dr Lorenzo suggested that they must be guided by a defined career progression framework relevant both locally and internationally. Improving data and information sharing and collaboration, monitoring, and performance evaluation through proper feedback mechanisms are also needed. Another recommendation was that the government should form bilateral and multilateral agreements with foreign countries to implement social security measure for workers. Policy recommendations Dr Lorenzo shared that there was a need for a policy scan to determine whose agencies mandates needed to be updated. Organizational policies need to be harmonized to minimize programme gaps. Primary or prioritized services should be assigned to key migration-related agencies. There was also a need to empower migrants, their families, and providers of services. Their roles need to be made clear. Organizational recommendations Finally, Dr Lorenzo talked about the International Organization for Migration (IOM) service providers in the Philippines in order to attempt to group agencies according to main functions available for migrant services. Dr Lorenzo also noted that in the case of Philippines, surprisingly, recruitment agencies had done a good job. In the end, Dr Lorenzo shared that presently, a nurse is in the Congress and representing their interests among the law makers. This was stated proudly by the speaker, thereby indicating the fact that Filipinos are proud of what their nurses have achieved globally. 12 P a g e

15 Responses Dr A Didar Singh Secretary General, FICCI According to Mr Singh, there are only three players in this world of migration: human resources, business, and the government. Migration is a fact of life. The legal framework is very important, which determines who and in what way they move. Everything else follows from this. According to him, guidelines as given in the WHO Code of Practice are meaningless unless they are made legal. Dr Noyal Thomas CEO, Norka-Roots Dr Thomas shared his experiences from Kerala, an area that leads the country in terms of migration. He believed that no matter what the regulation, people would migrate. The recommendations he offered were: Educating migrants through a pre-departure programme is very important to ensure safe migration, or else they will suffer. Migrants need to follow the norms in the host country. India needs to sign bilateral agreements with other countries, especially with the major destination countries. As proven, the countries with which there was an agreement were safe for migrants. He emphasized the need to regulate recruitment agencies. People need to be allowed to migrate legally and they need to be given options. There was also a need for reintegration of health professionals. He ended positively saying that highly qualified people were coming back to Kerala and establishing medical colleges, etc. This was a positive outcome as it would lead to employment generation. Open Discussion Mr J John of the Centre for Education and Communication, New Delhi, wanted to know what the differentiated needs of health workers were; what were the specific rights of health workers with regard to circular migration; and why would a health worker want to return back to her/his country? Mr P Narayan from the Trade Union Centre of India wanted to know why the Immigration Bill had not been passed after two years, and what was the NOIA doing about it? He also commented on the need to take serious and vigorous action against opportunistic and corrupt recruitment agencies. He gave an example of a recruitment agency which, despite being black listed in Bahrain, had engaged 128 Indian workers who were later jailed, and eventually only released after intervention with the king of Bahrain. Dr Angela Chaudhuri, Director, Swasti Health Resource Centre, wanted to know what the family rights and entitlements of health workers were, and what protection do Indian consumers have if 13 P a g e

16 a migrant health worker returns home after committing medical malpractice in the destination country? In her response to Mr John s question, Dr Lorenzo said that since Filipino health workers were technologically challenged, their expressed needs included skill-based training and development, and protection in terms of vaccinations, etc. The migrant health workers come back to their country to reunite with their families, while young people came back because they wanted to get married and wanted to have a familial social structure. Also, progressive circular migration needed to be encouraged when these migrants come home for Christmas and holidays. Dr Rajan responded by saying that the issue of return of migrants needed to be looked at very seriously. He agreed that the coordination among Indian ministries was a concern and gave an example of how presently Indian passports were overseen by three ministries. On the question of recruitment agencies, he agreed that there were some bad ones, but he emphasized that there were good ones also, adding that the media often only highlighted the bad practices, which tended to give an overly negative view. Session 3: The Assessment of Working Conditions of Foreign-trained Health Professionals in Europe Facilitator : Dr Khadria Dr Davide Calenda, Researcher, Robert Schumann Centre for Advanced Studies, European University Institute Investigating the working conditions of Filipino and Indian-born nurses in the United Kingdom According to Dr Calenda, the Philippines and India are the biggest sources of internationally recruited nurses (IRNs) for the OECD countries, including the United Kingdom. The case of the United Kingdom provides clear evidence of the importance of the state policy in influencing employers' utilization of migrant nurses as well as working conditions. The United Kingdom has a long-standing legacy of international staffing, and has developed changes in migration management and in entry requirements. Its policy has shifted from massive recruitment from 1998 to 2006, to a period called openness to mobility and to the introduction of progressive restrictions from 2006 onwards. His study raised the following questions: what are the working conditions of Filipino and Indian IRNs in the United Kingdom; what factors shape their working conditions; how do working conditions shape IRNs orientation towards the UK labour market; what lessons can be learnt from the UK s case; and what policy directions and recommendations can be drawn. Main observations made by Dr Calenda: 14 P a g e

17 A majority of the respondents reported a worsening of several dimensions of their working conditions since their arrival in the United Kingdom (i.e. job security, security in the workplace, career perspectives). Job insecurity has increased for five out of ten respondents since they started working in the United Kingdom, despite the fact that almost nine out of ten respondents are currently employed on a permanent basis. Only one out of 10 respondents considers that their position in the UK labour market had become more secure over the years. A majority of the respondents consider their working conditions worse compared to the working conditions of their colleagues working as a nurse in the same team or department, with the proportion highest among IRNs working in teams predominated by colleagues with UK origins. A majority of the respondents have personally experienced practices of harassment, bullying or abuse in the workplace, mainly by colleagues and patients, but many report unfair treatment from managers as well. Most of the respondents consider these practices as driven by ethnic discrimination. Problems with the recruitment process are widely diffused among IRNs across health-care facilities throughout United Kingdom. A large number of IRNs surveyed reported that they had been provided misleading information during the recruitment process, and had been charged a high fee by the recruitment agencies. Implications Demotivation and detachment: the more IRNs suffer from bad working conditions, the less they identify themselves with the organization they work for. Therefore the satisfaction with the quality of care they are able to provide to patients/service users also decreases. Re-emigration or return: according to Dr Calenda, many IRNs reported that they were planning to leave the United Kingdom to work as a nurse in another country or return home, as they were disappointed with their current working conditions, lack of career perspectives, and uncertain about their future in the United Kingdom. Examples included the high cost of living there and tightening immigration rules. Policy implications With regard to recruitment, Dr Calenda suggested that bilateral agreements should include clear measures to monitor the implementation of codes of ethical recruitment and to assess the impact of recruitment practices on the working conditions of IRNs after the arrival in the destination country. Trade unions and professional associations should be actively engaged in the monitoring system. Also, awareness needs to be generated among IRN candidates about what the real opportunities and risks are. Working conditions should be addressed both at the national level and at the level of health facility. Dr Calenda emphasized that there was no reliable data on how many migrants were in the United Kingdom and how many were leaving the country. According to his rough estimates, more than 400 nurses had reached the United Kingdom. 15 P a g e

18 Dr Tina Kuriakose Jacob, Head of Research, India Centre for Migration International mobility of nurses from Kerala to the EU: prospects and challenges According to Dr Jacob the number of Indian nurses in European countries is negligible with the exception of the United Kingdom and Ireland. For Indian nurses abroad, there are significant push and pull factors. The Gulf countries are seen as a stepping stone for nurses from Kerala. Overseas employment for these women had generated increased wealth, better conditions of work and prospects for professional improvement. Despite this positive impact documented in various studies, concerns remained on the supply side and the availability of an adequate nursing workforce in India. However, the push factors for such a choice are significant, given the poor salary structures, long working hours and bond system prevalent among private institutions in India, due to the high demand for nursing education. The mobility of nurses is demand-driven and network-enabled. Permanent residence is preferred by them, with migration seen as a life strategy. Interestingly, Dr Jacob also mentioned that migration of health professionals was not the sole reason for the health system collapsing in India. Dr Jacob explained that an EU survey in the Netherlands and Denmark was done to add to the existing literature and build a perspective on destination countries. Shortages in nursing staff were not particular to developing countries alone, and both Denmark and the Netherlands had experienced nursing deficiencies. A brief assessment of working conditions for Indian-trained nurses in Denmark revealed that while there was some scepticism over the portability of skills in a European context, experience with Malayalee nurses recruited by a private hospital in Denmark showed them well-endowed in practical skills once the language barrier was overcome. The working conditions were found to extremely favourable, with the nurses expressing happiness over the non-hierarchical working style and the flexibility of working hours, among other advantages. They made remittances to India. There was a discernible mismatch between immigration policy and labour market demand, with employers in the Netherlands having used loopholes in the Highly Skilled Migrants Scheme to recruit operation theatre assistants. Return migration: plans for returning to India were varied among the nurses, despite knowing that working and staying in Denmark was limited. However, none of the nurses saw themselves returning to work in India. Recommendations Medium-term policies needed for an organised and well-coordinated international recruitment; Online integrated labour market information system including a registry of skilled and qualified nurses in India; 16 P a g e

19 Responses Implementation of standards in nursing education through consultations with various stakeholders, and formal collaboration in nursing education to align training requirements with that of the EU; Encourage private recruiters towards ethical recruitment practices such as sharing credible and adequate information prior to recruitment on matters related to contract, salary, working conditions, etc; Apprenticeship/student exchange programmes/staff exchanges in nursing and allied services could be considered to facilitate mutual learning; and Incentives for return should include increased salaries, promotions and improved working conditions for nurses in India. Mr Krishna D Rao Public Health Foundation of India According to him, both papers have brought out interesting observations and thereby made a good contribution to the understanding of health worker migration. He lamented the fact that there was very little data on migration of health sector professionals to other countries. According to one study by All India Institute of Medical Sciences, in New Delhi 50 per cent of doctors pursuing their studies left the country -- a double loss to the country as these aspiring doctors attained their degrees from government institutions. Mr Rao said it needs to be seen how migration is affecting local capacities in different states. Kerala, for example, has an over capacity of nurses unlike in northern states like Uttar Pradesh. Mr Shiv Kumar Mr Kumar commented that both papers have a perspective and have moved knowledge forward. They have brought out important issues regarding gender, local unemployment, the negative impact of immigration laws on migration and anecdotal references to discrimination. On a lighter note, he mentioned that there s a joke that goes around in Kerala that the similarity between prawns and doctors is that the best ones are found in the Middle East. Unfortunately for him, that was the state of affairs of the health sector in Kerala. 17 P a g e

20 Session 4: The Effects of the Migration of Health Professionals on the Health Sector of the United Kingdom Facilitator: Dr SK Sasikumar, Senior Fellow, V.V. Giri National Labour Institute Dr Piyasiri Wickramasekara, Researcher and Vice President, Global Migration Policy Associates, Geneva Assessment of the impact of migration of health professionals on the labour market and health sector performance in destination countries Dr Wickramasekara began by mentioning the changing context of health professional migration, which included a concern about the high outflow of health professionals from poor origin countries, and development of codes of practice culminating in the WHO Global Code of Practice. With the global economic crisis, there has been a tightening of health budgets and moves towards self sufficiency in countries of destination, such as in the United Kingdom, which has set up more medical schools/nurse training. Frequent changes in immigration policies in the United Kingdom and less reliance on bilateral agreements and Memorandum of Understanding (MOUs) by countries of destination were some other aspects of the changing context for health professional migration. The objectives of Dr Wickramasekara s study were: Identify and analyse the impacts and effects the migration of health professionals are likely to have on host countries; Propose policy recommendations to enhance the positive impact of the migration of health professionals in host countries and mitigate any related negative effects; and Focus on the impact of health professionals migration on destination countries with regard to the labour market, the health system performance and the quality of care. With regard to the impact on the labour market, the questions were whether international health professionals (IHPs) drive down wages of IHPs and do they cause displacement of native health professionals? According to Dr Wickramasekara, most research does not support this view of immigration s negative impacts on wages and earnings. The general finding of a wide range of studies was that any negative effect of immigration on wages is small, if it exists at all. Also, numerous studies on Europe and the United States suggest immigrants do not displace natives in employment in any significant way. With regard to impact on labour mobility, Dr Wickramasekara stated that the studies did not find any evidence to suggest that health-worker migration led to movement of native health workers from areas of high concentration of immigrant health workers. The impact was either absent or insignificant in most cases where an impact was found. With regard to the impact of IHPs on health sector performance, Dr Wickramasekara stated that migrant health workers have contributed considerably to expansion of the delivery of services, 18 P a g e