Health Workforce Mobility: Migration and Integration in Australia Lesleyanne Hawthorne Professor International Health Workforce Centre for Health Policy WHO 4 th Global Forum on Human Resources for Health (Dublin) Health Workforce Mobility Comparing Migration and Integration and Its Gender Dimensions 14-17 November 2017
Trend 1. Recent Growth in Degree-Qualified Migrants Admitted to Australia by Major Field 2006-11 (Compared to 2001-05) Field 2001-2005 Arrivals 2006-2011 Arrivals Engineering 18,790 41,407 Accounting 26,145 35,423 IT 22,630 31,968 Education 15,400 29,464 Nursing/ Midwifery (RN Degrees) 8,584 16,154 Medicine 7,241 12,696 Nursing (RN Diplomas) 5,649 10,194 Pharmacy 1,798 3,005 Dentistry 1,063 2,343 Physiotherapy 755 1,556 Total (All Degrees) 192,940 347,611
The Latest Data: Temporary Compared to Permanent Health Workforce Migration Skilled Category (2008-09 to 2015-16)
Skilled Migration Category Only - New Visa Grants by Major Health Field (8 Years to 30 June 2016) TOTAL = 95,873 (46,338 Temporary + 49,535 Permanent) Nursing (RNs) = 48,936: Permanent = 30,132 Temporary = 18,804 Medicine = 33,675: Permanent = 10,903 Temporary = 22,772 Dentistry = 2,467: Permanent = 1,537 Temporary = 930 Pharmacy = 2,251: Permanent = 2,053 Temporary = 198 Physiotherapy = 1,843: Permanent = 1,037 Temporary = 806
Trend 2. Reliance on Temporary Migration to Address Workforce Maldistribution Medicine 457 Visa: Employer-selected District of Workforce Shortage locations 22,772 medical migrants selected 2008-09 to 2015-16 Key demand = GPs, RMOs Permanent skilled migration program pathways: Employer-Nominated Points-tested Independent Regional/ State sponsored Recent growth
Location of Temporary Visa New Medical Grants - Regional Demand (2008-09 to 2015-16)
Compared to Location of Temporary Sponsored Nurses Sector Demand (2008-09 to 2015-16)
Trend 3. Ensure Responsiveness to Workforce Demand (Reduction in New Grants for Temporary Health Professionals as Labour Market Tightens (to June 2016). Field 2012-13 2015-16 Total 2008-09 to 2014-15 Non-Food Trades 13,541 6,499 71,075 IT 8,604 8,923 62,370 Health 6,517 4,196 46,338 Engineering 3,583 1,097 23,643 Education 2,345 1,750 13,434 Accounting 1,530 982 9,010 Total Fields 68,481 45,395 418,777
Temporary Migration Declines: Nursing + Allied Health Fields Signals Future Reduced Permanent Migration? Nursing 2008-09 = 4,073 2015-16 = 1,066 Dentistry: 2008-09 = 156 2015-16 = 34 Physiotherapy: 2008-09 = 102 2015-16 = 77 Pharmacy: 2008-09 = 16 2015-16 = 41 Growth in domestic student training
Compared to Medicine Reliance on Temporary Migrant Doctors to Work in Undersupplied Sectors and Sites (2008-09 to 2015-16) Year / Total Number Permanent Medical Migrants Number Selected Temporary Medical Migrants Number Selected 2008-09 970 3,312 3,758 2009-10 1551 2,673 2010-11 1018 2,927 2011-12 1544 3,299 2012-13 1736 2,855 2013-14 1468 2,440 2014-15 3,139 2015-16 4,080 TOTAL 33,675 1267 2,063 1349 2731 10,903 22,772
Trend 4. Impact of Differential Entry Pathways + Country of Training on Registration + Employment Outcomes 1. Permanent skilled migrants (128,550 68% of PR s) 2. Temporary workers (94,890 PA s Oct 2016 no cap ) 3. International students (645,000 enrolled 2016 - stay?) 4. Family migrants (57,400) 5. Humanitarian migrants + asylum seekers (13,500) 6. Syrian refugee special intake (12,000 to March 2017)
Top 10 Source Countries for Migrant Health Professionals Selected by Australia: 8 Years to 30 June 2016 = 95,873 as Skilled Migrants Temporary = 46,338 1. UK (13,910) 2. India (8,245) 3. Ireland (3,692) 4. Philippines (3,310) 5. Malaysia (2,322) 6. Canada (1,569) 7. South Africa (1,177) 8. Sri Lanka (1,167) 9. USA (1,090) 10. China (1,045) Permanent = 49,535 1. UK (10,478) 2. India (9,795) 3. Philippines (4,730) 4. China (3,707) 5. Malaysia (2,954) 6. Ireland (2,180) 7. South Africa (1,400) 8. Korea (South) (1,382) 9. Nepal (1,020) 10. Zimbabwe (1,020) THEN Pakistan, Singapore, Iran, Zimbabwe, Germany, Korea THEN Singapore, Canada, Sri Lanka, Pakistan, HK SAR.
The Challenge: Securing Vocational Registration + Health Workforce Employment Pre-migration screening for human capital attributes: YES Skilled migrants (temporary + permanent) NO Family and humanitarian migrants CASE STUDY Refugee doctors Mandatory English language testing IMPACT - By source country and field Access to vocational registration after assessment: Immediate eligibility Australian qualification Conditional registration (with practice limitations) Bridging programs (eg nursing) Re-qualification
Australia s Growing Preference: For UK Medical Migrants (2008-09 to 2015-18 New Visas)
The Impact of English Language Testing on Vocational Registration by Major Field: Australian + NZ Occupational English Test Outcomes (2007-11) Pass rates: Nurses (17%) Pharmacists (38%), Doctors (52%), Dentists (62%) Candidate pass rate (%) 70% 60% 50% 40% 30% 20% 10% 0% 53% 43% 52% 20% 19% 17% 40% 47% 62% 38% 39% 38% 34% 32% 28% 46% 40% 37% 41% 32% 34% 2005 2010 2011-10%
Defining Exemptions from Australian Medical Council Exams for Migrant Doctors - Variable Registration Pathways 2008+? X Fast Medium Slow Specialists
Australian Medical Council: The Competent Authority Pathway (Impacts of Attractiveness of Australia for IMGs) Places of training: 55+ (growing!) Place of prior registration: 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 Case study = Doctor qualified in China
Intra-OECD Flows Ireland 2008-09 to 2015-16 Loses 1,759 Doctors + 2,918 Registered Nurses to Australia Year Medicine Nursing All Health Fields 2008-09 Temporary Permanent 2009-10 Temporary Permanent 2010-11 Temporary Permanent 2011-12 Temporary Permanent 2012-13 Temporary Permanent 2013-14 Temporary Permanent 2014-15 Temporary Permanent 2015-16 Temporary Permanent Total Temporary Permanent 137 16 174 28 159 24 216 48 173 47 177 59 163 48 226 64 1425 334 GRAND TOTAL 1759 2918 5872 163 71 154 96 165 101 236 161 316 147 210 275 167 256 160 240 1571 1347 338 112 391 151 425 154 601 254 656 266 479 451 378 405 424 387 3692 2180
MCQ Examination Pass Rates - Top 10 Candidate Countries 2015-16 (AMC 2016 Annual Report) Australian Medical Council 337 Total candidate Percentage pass 246 238 58.5 69.9 151 59.7 62.3 137 130 126 42.3 70.8 73.8 110 97 51.8 44.3 88 69.3
Impact of Country of Training: On Australian Medical Council MCQ and Clinical Examination Pass Rates on 1-4 Attempts (2016 Report) Country of Training MCQ No. Candidates Passes 1-4 Attempts Pass Rate Clinical No. Candidates Passes 1-4 Attempts Pass Rate India 337 197 58% 347 98 28% Egypt 246 172 70% 52 18 35% Pakistan 238 142 60% 231 73 32% Bangladesh 151 94 62% 226 62 27% China 137 58 42% 75 19 25% Iran 130 92 71% 131 39 30% Sri Lanka 126 93 74% 129 37 29% Philippines 110 57 52% 115 26 23% Russia 97 43 44% 72 20 28% Nigeria 84 44 52% 49 4 8% Myanmar 82 60 73% 115 39 34% Malaysia 50 35 70% 32 14 44% South Africa 34 26 76% 21 15 71% Total 2418 1447 60% 1997 571 29%
Impact of Registration on Employer Choice: Medical Migration Source Countries (2015-16) Temporary 457 Visa Stock Resident Year to 30 June 2016 54% = UK, Ireland, Canada, USA Permanent Skilled Category Total Selected Year to 30 June 2016 41% = UK, Ireland, Canada, USA UK (38%) UK (29%) Ireland (8%) Malaysia (12%) Malaysia (8%) India (9%) India (8%) Canada (7%) Canada (6%) Singapore (5%) Sri Lanka (4%) Ireland (5%) Singapore (3%) Sri Lanka (4%) USA (2%) Pakistan (4%) Myanmar, S Africa, Pakistan (2%) Myanmar (2%) Nigeria, South Africa (1%)
Employment in Field of Qualification for Health Professionals by Select Source Country Within 5 Years of Arrival: Impact of Bridging Courses in Nursing (2011) Medicine 57% overall S Africa (83%) UK (74%) Canada (64%) Europe - SE (61%) India (61%) Europe NW (59%) Singapore (56%) Philippines (47%) Europe E (27%) Vietnam (12%) China (8%) Indonesia (4%) Nursing (RNs) 66% overall UK (82%) S Africa (80%) Singapore (77%) India (74%) China (61%) Europe NW (59%) Europe - E (59%) Vietnam (58%) Philippines (56%) Canada (55%) Europe SE (54%) Indonesia (46%)
Trend 5: The Productivity Premium Facilitate International Student Two-Step Migration (Health Sector) 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%
Where Are Migrant Health Professionals Increasingly Selected? By Permanent Skilled Sub-Category 2008-09 to 2014-15
Case Study Where Are Migrant Nurses Now Selected (Permanent Skilled Migration)? Australian Nursing and Midwifery Assessment Council: 10 years back Minimal onshore selection 5 years back Around 1/3 selected onshore 2016-17 data 4,691 applications received 76% selected onshore with an Australian qualification Around 30% have only an Australian degree Main source countries = Philippines (1167) + India (781) NMBA Transformation of bridging course providers C39 to just 9 (with much strengthened QA requirements)
Trend 6. Immigration Policy Volatility (Reflecting Expanded Domestic Training) Current temporary visa: Abolished, to be replaced by two eligible lists 215 banned occupations: 17 in allied health fields (including dental hygienists, therapists and prosthetists, mothercraft nurses, psychotherapists) New Medium and Long-Term Strategic Skills List: 178 professions and trades including 66 health occupations (GPs, most medical specialties, most fields of nursing 4 years, scope to apply for extension, and convert onshore to permanent resident status
March 2018 Changes to Temporary Migration of Relevance to Health (continued) Short Term Skilled Occupation List: Just 2 (rather than 4) year entry for 253 occupations Eligibility to apply for just one extension No capacity to stay Includes: Resident medical officers (2 nd biggest source of migrant doctors) Dentists, dental specialists and technicians Pharmacists Nurse educators and managers, and enrolled nurses Paramedics Impact on future scale of flows and Australia s global attractiveness as a destination?
Select Recent Sources: Data in Presentation Australian Medical Council (2016): Annual Report 2015, AMC, Canberra Department of Immigration and Border Protection (2016-17): Provision of unpublished skilled migration arrivals data (analysed by L Hawthorne & C Higgs, Centre for Health Policy, University of Melbourne, for forthcoming publication) Hawthorne, L (2013), Health Workforce Migration to Australia Policy Trends and Outcomes 2004-2010, Health Workforce Australia, Adelaide Hawthorne, L & To, A (2013), English Language Skills Registration Standards An Australian and Global Comparative Assessment, Australian Health Practitioner Regulation Agency, Melbourne, 169pp Hawthorne, L (2014), WHO Four Country Study Health Workforce Migration in Australia, Chapter 9 in Migration of Health Workers WHO Code of Practice and the Global Economic Crisis, Eds A Siyam & M Dal Poz, World Health Organization, Geneva, pp 109-132 Hawthorne, L & To A (2014), Australian Employer Response to the Study-Migration Pathway: The Quantitative Evidence 2007-2011, Highly Skilled Migration: Politics, Processes and Politics Special Issue, International Migration, 52(3): 99-115, August Hawthorne, L & To, A (2014), The Early Migration and Career Trajectories of International Medical Students Qualified in Australia, Medical Deans of Australasia, Sydney, 66pp, http://msod.webd3.com.au/publications-reports/other-reports Hawthorne, L, Hazarika, I & Remedios, L (2014), Review of the Australian Physiotherapy Council Assessment Process for Overseas Qualified Physiotherapists, Australian Physiotherapy Council, Melbourne 127pp. Hawthorne, L (2015), The Impact of Skilled Migration on Foreign Qualification Recognition Reform in Australia, Canadian Public Policy Journal, August, http://www.utpjournals.press/toc/cpp/41/supplement+1 Hawthorne L (2017 in press), International Health Workforce Mobility and Its Implications in the Asia-Pacific Region, World Health Organization, West Pacific Regional Office, Manila Hawthorne, L & Higgs, C (2017 current review), Is Australia s Level of Reliance on International Medical Graduates Changing?, submitted to Medical Journal of Australia November 2017