Health worker migration still shaping healthcare after COVID-19

Case studies collected by the People’s Health Movement (PHM) reveal how the migration of health workers continues to shape health systems around the world, with the Global South still bearing the greatest burden of the brain drain, despite facing the most severe workforce shortages to begin with. In a webinar held on October 25, chaired by health systems thematic group co-coordinator Jamie Dasmariñas, PHM activists from India, Indonesia, the Philippines, and Kenya examined key developments in health worker migration since the COVID-19 pandemic, supported by inputs from WHO Europe’s Sulakshana Nandi.

One of the shared findings across Asian case studies highlighted the sizable mismatch between the number of people completing health-related education and those actually finding employment in local health systems. Due to a lack of investment into public health systems, many workers in the sector face poor working conditions and low pay, making migration the only option. Without decisive actions and meaningful reforms from governments, this imbalance will continue to drive migration and deepen inequities in care. But some governments in the region – like the one in the Philippines – continue to turn nurses’ migration into a national brand instead, additionally destabilizing health services.

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At the local level, migration is producing serious consequences for specific population groups. Describing the situation in Indonesia, PHM activist Nurbaya reflected on the contrast between urban and rural staffing. While health centers in large cities are often overstaffed, it remains difficult to fill posts in more remote areas. “Instead of the surplus of domestic health workers leading to internal migration to underserved regions, it is leading to increased migration abroad, particularly among nurses and other medical personnel,” Nurbaya explained.

Such migration trends can be tied to changes in education, the related case studies suggest. “The number of nursing schools in Indonesia expanded significantly, from 409 institutions in 2004 to 826 in 2017,” Nurbaya said. “As a result, the country produces at least 100,000 new nursing graduates annually. Most of this expansion has taken place in more developed regions, admitting more candidates from urban and privileged backgrounds. For many, there is limited or no interest in working in rural or remote areas. Many join nursing courses hoping to work abroad.”

Disparities between the number of nurses graduating each year and the limited number of posts in public health services have also served as a major push factor elsewhere, including in India. Drawing from experiences in Kerala, Meghalaya, and Puducherry, Rakshita Khanijou from the World Health Organization (WHO) office in India touched upon the rapid growth of private nursing colleges. “In India, nursing education is divided between subsidized public colleges and costly private institutions, many of which are geared toward preparing students for overseas placement,” notes one of the case studies discussed by Khanijou.

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More recently, however, different trends seem to have appeared. The left-governed state of Kerala, from where many nurses have been recruited to European and West Asian countries, has started to see a significant number of nurses return. According to local health sources, tens of thousands have come back and successfully reentered local services. This experience suggests that Kerala’s approach – prioritizing access to healthcare and actively employing health workers – has helped in the achievement of recent milestones in the sector.

While India’s experience shows that migration cannot be regarded as the sole driver of workforce deficits – its extent and impacts strongly related to governments’ preparedness to strengthen and invest in the health sector – its effects are possibly more pronounced in Africa, as illustrated by PHM Kenya’s Dan Owalla. Despite severe domestic shortages, the Kenyan government has negotiated bilateral deals with high-income countries, notably Germany, that promote labor migration. The German government has made similar agreements with other countries of the Global South, such as Brazil, under the assumption that these nations have a “surplus” of health workers – without questioning the underlying causes, such as chronic underfunding of public health systems and related staffing issues.

Read More: Health worker brain drain to global north is fueled by erosion of workers’ rights and health systems

Together, PHM’s case studies show that migration remains an indicator of broader structural inequities in global health, strongly related to privatization and inability of Global South countries to allocate adequate resources to the health sector. Together with experiences collected from Papua New Guinea and Nigeria, PHM’s studies on this topic aim to further strengthen the call for global action to protect health workers’ rights and build equitable public health systems.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.