The migration of doctors and nurses from South Pacific Island Nations

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Abstract

Little is known of the structure of the international migration of skilled health professionals. Accelerated migration of doctors and nurses from the Pacific island states of Fiji, Samoa and Tonga to the Pacific periphery is part of the globalization of health care. The findings from a recent survey of 251 doctors and nurses from the three island countries are reported here. Key determinants of both present migration status and future migration intentions were analyzed using econometric methods. Nurses’ and doctors’ propensities to migrate are influenced by both income and non-income factors, including ownership of businesses and houses. Migrants also tend to have more close relatives overseas, to have trained there, and so experienced superior working conditions. Migration propensities vary between countries, and between nurses and doctors within countries. Tongan nurses have a higher propensity to migrate, mainly because of greater relative earnings differentials, but are also more likely to return home. The role of kinship ties, relative income differentials and working conditions is evident in other developing country contexts. Remittances and return migration, alongside business investment, bring some benefits to compensate for the skill drain. National development policies should focus on encouraging return migration, alongside retention and recruitment, but are unlikely to prevent out migration.

Introduction

This paper seeks to examine the rationale for the migration of skilled health professionals (SHPs) from a group of three Pacific island countries (PICs)—Fiji, Samoa and Tonga—in each of which there has been a considerable international skill drain from the health sector. Despite its growing significance, hitherto there have been few studies of the migration of SHPs, especially from developing states, and none that examine the structure of migration at both source and destination. The role of human resources is central to development, especially in small states, and the limited availability of skilled human resources can be a constraint to development. In the health arena the significance of human resources is doubled; SHPs directly improve the quality of life for others, who are then able to contribute more to the wider society. Conversely the lack of availability of skilled health workers has harmful ramifications for the rest of society. This paper examines one particular facet of that availability: the role of international migration in the changing distribution of SHPs.

In most island states there is a continued need to ensure that training and education are relevant to the particular situation of small states, in terms of local constraints and requirements. This has been better achieved in the Caribbean than in the South Pacific because of a lack of resources in the latter group of countries to make appropriate curriculum changes (Commonwealth Secretariat, 1997, p. 130; cf. Walt et al, 2002). Hence training within the Pacific region has rarely produced adequate numbers of SHPs. The lack of adequate numbers of appropriately skilled health workers, has been exacerbated, particularly in the smallest states, where there is migration (and thus attrition) of the labour force.

Migration of SHPs into, within and from the PICs is widely considered to be a growing problem. It affects core national strategies for health sector development, creating problems for health care and for human resource planning and development. Training of SHPs is particularly costly because of the long duration, the high costs of teaching materials and techniques (and the need for post-graduate education and training programs) and the limited resources of PICs. Consequently the loss of SHPs is unusually costly. Replacements may also be costly (and may be lacking in appropriate skills, languages and cultural sensitivity), thus creating potential problems in satisfying basic needs, achieving sustainable health strategies and developing healthy islands.

Hitherto no comprehensive study has been undertaken of the migration of SHPs within the context of regional (even global) labour markets. Consequently there is inadequate information on the rationale and impacts of the migration of SHPs, or the particular forms of migrant selectivity. The evidence that is available points to some worsening of the situation, in terms of attrition and migration rates, during the last decade, accompanying the widespread down-sizing (or stabilizing) of public service numbers. The situation in the PICs was already a source of concern a decade ago: ‘The region faces a crisis in terms of its health work force, not only in terms of direct care providers but at all levels of the system. It is not surprising that one of the most frequently mentioned topics is the shortage of doctors…The physician shortage is only the tip of the iceberg…Inefficiency in health systems is a major problem and there is a crucial need for trained administrative personnel’ (Lewis, 1990, p. 84). It is in this deteriorating context that the present study is situated.

In the Pacific and elsewhere little empirical information exists about the international migration of SHPs. This paper reports the findings of a survey conducted in 2001–2002 among SHPs in three PICs and two destination countries—Australia and New Zealand. SHPs were interviewed in both origins and destinations. Using data from the survey a statistical analysis was undertaken of the determinants of migration (and return migration) among the sampled doctors and nurses. Hence this is a unique study of the determinants of both migration and return migration. It is also unique in terms of the method applied, since it surveys three categories of SHPs: current migrants, return migrants and non-migrants (stayers). The consolidated data set is then analyzed using econometric methods. The method and conclusions are potentially applicable both to island states elsewhere, notably in the Caribbean where there are structural parallels (Connell, 1991; Connell & Conway, 2000), and to other countries where the populations are much larger and the migrants much more widely dispersed (e.g. Philippines or South Africa), though comparable surveys in those countries would be extremely difficult. In this respect the South Pacific could be conceived as a ‘laboratory’ for analyzing the determinants of migration among SHPs in general.

The paper is structured as follows: the following sections discuss: the background to migration of SHPs in the South Pacific; the survey; the specification of the three models of migration; the descriptive statistics and econometric results; relative deprivation in terms of comparative income levels; and, conclusions.

Section snippets

Migration in Pacific Island nations

Since the 1960s there has been a very substantial rise in the extent and significance of migration within and from the PICs. The most substantial emigration streams in the region have come from the central Polynesian states (including Tonga and Samoa). However there has long been a significant migration stream of Indo-Fijians from Fiji to several metropolitan destinations. In terms of the migration of SHPs this is the most important stream in the region (Connell, 2002). Fiji is the largest

The survey

The global rise in the migration of skilled workers has been perceived as a response to the accelerated globalization of the service sector. Such professional services as health care are very much part of the new internationalization of labour (e.g. Gish & Godfrey, 1979; Buchan & O’May, 1999; Hardill & MacDonald, 2000; Raghuram & Kofman, 2002). In the South Pacific as elsewhere, the migration of SHPs is no new phenomenon. At least as early as 1989 a medical degree from the Fiji School of

Current migration status

The complexity of international migration is considerable. Economic variables, and especially the relationship between income levels and cost of living, are of key relevance in influencing migration decisions. According to human capital theory, people tend to migrate if predicted earnings (estimated relative to age, education and years of work experience) and real incomes set against costs of living are greater in the destination country (Harris & Todaro, 1970; Borjas & Bratsberg, 1996). Social

Descriptive statistics

This section uses the dataset from the survey to test the above models explaining migration status—propensities to migrate and to return home—and the migration intentions of non-migrants, for nurses and doctors in the three sampled countries. The names and sample means of the variables used in the analysis are given in Table 2.

The mean values for the same variables for each of the three migration status categories are given in Tables 3a and b. As expected, nurses and doctors who are current

Relative income differentials within and across countries

One important finding to emerge from the regression analysis was that Tongans have a higher propensity to out-migrate, a higher propensity to return home, and, among non-migrants, a higher stated intention of future migration, in comparison with Fijian and Samoans. It was noted earlier that country of birth variables are likely to be capturing the effects of a number of unobserved variables. This section explores possible interpretations of these results.

Tongan migrants appear to do better than

Conclusion

The present study has demonstrated that income is a major influence on decisions to join the health profession, for both nurses and doctors in each of the three PICs. It is also a key reason for international migration. Tongans have a significantly higher propensity to migrate, and the differential between mean incomes of nurses and the national mean per capita income was greatest in Tonga. This ‘push’ factor could explain why Tongan nurses are more likely to migrate than Fijians or Samoans.

Acknowledgements

The authors wish to thank WHO for funding the surveys on which this study is based, and Gareth Leeves (School of Economics, The University of Queensland), two anonymous referees and Stephen Birch for their useful comments on the original draft.

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