Worldwide, the health worker profession relies on migrants. But policy often restricts their movement. The COVID-19 outbreak has shown that, under crisis, many of these barriers are more malleable than policymakers make them out to be.
In most high-income countries, migrants make up a large share of health workers. Today, one in six doctors across OECD countries studied abroad, and in the last decade, the number of foreign-born doctors and nurses in the region grew by 20 percent. Migrants make up 12 percent of the 1.9 million-strong UK health workforce, and 17 percent of the 12.4 million-strong US health workforce. Of course, foreign-born health workers may have studied in the country they migrated to, not in their home country—perhaps because they moved with their family when they were young, or because they moved for study. Regardless, health systems today rely on migrant health workers. In particular, migrants are disproportionately employed in pandemic-response frontline occupations—meaning migrants are more likely to be on the frontlines of COVID-19 response than other health workers.
Understanding the resistance to health worker migration—and why it’s faltering now
Despite their reliance on foreign-born health workers, high-income countries have historically resisted increasing health worker migration, particularly for health workers trained abroad. There are two main reasons for this reticence. First, high-income countries worry these workers will not have the required level of skills. Second, they worry that facilitating health worker movement would deprive countries of origin of their (much-needed) health workforce. This second concern becomes an ethical question, one that the 2010 World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel sought to address by discouraging active recruitment from 57 countries where the WHO identified a “critical shortage” of health workers. This only precludes “poaching” of workers by recruitment agencies—not bilateral agreements between two equal parties, such as that between the UK and the Philippines whereby the latter agrees to provide trained health workers in exchange for workforce development and best practice sharing. But this nuance is not well understood by many countries, and the WHO code is often used to bar such agreements.
In addition, much of the health workforce —technicians and care workers, for example—is deemed “low-skilled” in high-income countries, which makes such migration more difficult. As an example, in February 2020, the UK unveiled its new points-based immigration system to govern migration once the UK leaves the European Union. Under the proposed new rules, those who aren’t able to earn over £25,000 per year in the UK are barred, unless the government deems there to be a shortage in the particular sector. Many government officials deemed people in this bracket as “low-skilled.” This earning requirement covers many health workers now deemed “key” by the UK government in the face of the COVID-19 epidemic, including paramedics, nurses, carers, and midwives. As a Brexit-supporting member of parliament recently said,
“One of the things that this current crisis is teaching us is that many people that we consider to be low skilled are actually pretty crucial to the smooth running of our country and are in fact recognised key workers.”
COVID-19 shows that barriers to health worker migration are surmountable in times of crisis. An interesting development in the past few weeks has been the softening of restrictions on foreign-trained and -born health workers in high-income countries to cope with the crisis. Workers have been flown in to hard-hit countries from overseas (e.g., Chinese, Cuban, and Albanian doctors recently moved to Italy) and internal restrictions have been lifted. Refugee doctors without recognized qualifications are being called up in Germany, and having their recognition fast-tracked in the UK. New York is allowing foreign-trained doctors to work, and Australia is lifting working hour caps on foreign-trained nurses. These examples show that when desperate, high-income countries are willing to overlook the apparently insurmountable barriers detailed above. And with COVID-19 spreading, these countries are about to become even more desperate.
To address health worker shortages, countries should increase migration
High-income countries, where the outbreak is most severe, already face huge health worker shortages. There are an estimated 44,000 nursing vacancies in the UK, predicted to increase to 100,000 within the next decade. A Global Burden of Disease Study (2017) estimates that the US will need one million more nurses by 2020, while India faces a shortage of over 3.9 million doctors and nurses. Under normal circumstances, a lack of available nurses can mean fewer available hospital beds and worse outcomes for patients. Across income brackets, only half of all countries have the needed workforce to meet the health-care needs of their populations—and that’s without the added burden of a pandemic.
During the COVID-19 epidemic, existing shortages of health workers are likely to become more pressing (and deadly) as health workers themselves become infected. Doctors and nurses account for 15 percent of infections in Wuhan, 14 percent in Spain, and 10 percent in Italy. And these numbers may very well be worse in the US, given the shortages of protective gear, which has already lead to two deaths and hundreds of infections in New York City. In the UK, the National Health Service just lost its first consultants to COVID-19, raising fears of what’s to come. Jen Kates of the Kaiser Family Foundation’s Global Health Program notes that “with already lower staffing ratios plus the very real risk of losing more [health care workers] due to illness, this could spiral and get much worse.”
Beyond COVID-19, health worker shortages are going to be increasingly impactful. We have long been warned that demographic shifts in aging societies in OECD countries will put pressure on health systems. The WHO estimates that by 2030 there will be a worldwide shortage of 15 million health workers. In addition, all evidence points to the fact that pandemics are likely to become increasingly common in the future (due to increased global travel and integration, urbanization, changes in land use, and greater exploitation of the natural environment). We are likely to face another global pandemic in our lifetime—without intervention, aging and growing populations will mean even larger health worker shortages than there are today.
All this points to a need for countries to expand health worker migration in two ways:
1. A rapid influx of workers to countries facing outbreaks like COVID-19
There is growing evidence that COVID-19 could become cyclical and seasonal, with outbreaks now emerging in the Southern Hemisphere as it enters its winter season. This suggests that at any given time in the next 12-18 months, there are likely to be sets of countries experiencing outbreaks and sets of countries experiencing suppression. In the immediate future, to prevent unnecessary deaths, policymakers should build systems for the rapid movement of health workers, so that countries in remission could mobilize their surplus health workers to fill shortages and provide relief support to countries in the midst of an outbreak. To do so, high-income countries will need to consider recognition and vetting of skill certifications, flexible visa issuance, and intermediation and worker support.
Recognition and vetting of skill certifications
Healthcare is a highly regulated profession, requiring that practitioners’ skills are certified before they can be employed. These certifications are generally delivered by national or state/regional certification bodies, and are often not transferable between nations and regions unless there is a mutual recognition agreement. While health workers certified abroad may have the technical skills to fill emergency shortages, getting certified for a specific labor market is a lengthy process and would undermine the ability to form a rapidly mobile health worker force. However, as noted above, several governments such as New York, UK, and Germany are all waiving local accreditation requirements to allow migrant and refugee doctors to practice with their existing foreign certifications.
Flexible visa issuance
Not only is visa issuance a famously lengthy process, but it is often tied to a specific employer and not sufficiently flexible to allow workers to move countries as outbreaks emerge. One option in response to this would be to recruit from refugees and asylum seekers who are already in the country and therefore do not need a new visa, as in the examples above. Another option would be for some countries to offer approval of visas on arrival for emergency workers in response to humanitarian crises; this could be applied to emergency pandemic response teams.
Intermediation and worker support
There should be a system in place for identifying potential recruits and matching them to hospitals with vacancies, and a support system for the medical staff to manage a recruit’s migration process from beginning to end (this is particularly crucial in a crisis where the context is likely to evolve rapidly, with border closures for example). Open Society Foundation is currently piloting such a system to identify willing foreign-trained doctors by reaching out to communities of migrants and refugees.
2. A long-term strategy to increase the global stock of health workers through bilateral agreements
In the long term, high-income countries will need to develop bilateral agreements with countries of origin to train potential health workers in skills needed in both countries. One such model is a Global Skill Partnership, which has been demonstrated to deliver economic and health benefits for all involved. A Global Skill Partnership between two equal parties does not violate the WHO Code, and “brain drain” does not occur. This model provides a way for all countries to increase their health worker stock, increase the skills of their health workers, alleviate concerns about social and economic integration, and, crucially, alleviate staffing shortages in key skills (such as aged-care and pandemic response).
High-income countries already suffer severe health worker shortages; the promise of future pandemics, along with complications from aging societies, will increase this pressure. Only by implementing proactive strategies to increase health worker migration, both in the short and long term, will we be prepared for what’s to come.