1. Presentation to Irish Forum for Global Health, Maynooth 29 th November 2010 Population Health Sciences, Royal College of Surgeons in Ireland Ruairí Brugha Professor Ruairí Brugha Dr Niamh Humphries Division of Population Health Sciences, RCSI. The Global Code on Health Worker Migration – marking Ireland’s score card

2. Health worker shortage – Global + Africa 4.3 million health worker shortage world-wide (doctors, nurses + midwives) – 36 of 57 hardest hit countries sub-Saharan Africa Minimum necessary to scale up essential health care – 21 doctors and nurse per 10,000 population. Ethiopia: –66,300 HWs in 2009 – aiming for 193,264 by 2020 – which will give it 8.5 per 10,000! Zambia: –9.8 per 10,000 reported in 2007 –we found Urban circa 6.5. Rural fell from 2.9 (2004) to 2.1 per 10,000 (2007) Malawi: –“More Malawian doctors in Manchester than Malawi” –Circa 8-10 trained surgeons in Malawi (population 15.5 million) USA –Will recruit half a million foreign-trained health workers in next 10 years – WHY? –Cheaper than to train them? US trained doctors get the best jobs?

3. Factors fostering health worker migration FACTORSPUSH / PULLREGULATORY ENDOGENOUS (Within the health system)  Salary levels  working conditions / career development opportunities  job satisfaction  Registration and licensing regulations  Codes of practice EXOGENOUS (outside the health system)  Quality of life  War / civil conflict / repression  Opportunities for children ’ s education  Immigration / emigration laws  Employment regulations Adapted from Padarath

4. International recruitment of health personnel: Global Code of Practice Global Policy Advisory Council + Technical Working Group –High level (ministers of health, donors, global policy makers) –8 international meetings, 2007-10 –Co-Chairs – Hon Mary Robinson + Dr Francis Omaswa Global politics –2008: almost derailed by Pres Bush administration –2009: WHO given more visible leadership to steer it thru WHA Global health code – only the second ever –first = code on breast milk substitute marketing, 28 years earlier Population Health Sciences, Royal College of Surgeons in Ireland (References: An Bord Altranais (Irish Nursing Board)

5. Objectives of the Global Code a)to establish and promote voluntary principles, standards and practices for the ethical international recruitment of health personnel in order to achieve a balance between the rights, obligations and expectations of source countries, destination countries and migrant health Personnel b)to serve as an instrument of reference for Member States in establishing or improving legal and institutional frameworks required for the international recruitment of health personnel and in formulating and implementing appropriate measures c)to provide guidance when developing bilateral agreements and other international legal instruments, both binding and voluntary d)to facilitate and promote international discussion and advance cooperation on matters related to the ethical international recruitment of health personnel as part of strengthening health systems, with a particular focus on the situation of developing countries NATURE + SCOPE: (i) Voluntary (ii) Global(iii) Ethical Principles

6. Percentage of nurses who are foreign trained OECD 2008 Ireland = 47% New Zealand 22%

7. 1.Analysis of Secondary Data Registration data from the Irish Nursing Board Immigration data from Dept of Enterprise, Trade & Employment. 2.Qualitative in-depth interviews with 21 Migrant Nurses Transcription of interviews Thematic analysis, supported by Max QDA 3.Quantitative national survey of 337 Migrant Nurses (structured questionnaire with open response answers) Postal survey via the Irish Nursing Register (308) Hospital-based recruitment (28). Population Health Sciences, Royal College of Surgeons in Ireland Nurse Migration Study: HRB 2006-09 Research Methods

8. Ireland’s Newly Registered Nurses 2004-2008 Population Health Sciences, Royal College of Surgeons in Ireland [Source: Irish Nursing Board]

9. Ethical Recruitment (1) Effects on sending countries? 3.3: Technical and financial assistance – developed countries to provide Health systems strengthening (HSS) and HRH assistance to developing countries SCORE:√√√  √? 3.5, 4.3, 4.4: International recruitment practices –Principles of transparency, fairness, promote sustainable source health systems –Ethical responsibility to health workers – information to make informed decisions –Fair and just recruitment and contractual practices –Equal opportunities and treatment to domestic HWs – induction, training, promotion International nurse recruitment campaigns delivered 11,288 non-EU new nurses into the Irish health system, 2000-2008. 278 (83%) stated that a recruitment agency facilitated their migration to Ireland –34 recruitment agencies: 9 Irish, 4 international, 21 local –54% of respondents used one of 2 Irish agencies 45% of these nurses were from Philippines, 45% from India (4% from 42 countries) Philippines has managed nurse emigration programme. India (esp Kerala) ? SCORE:√?

10. Ethical Recruitment (2) Information to migrants? 4.4: “Recruiters and employers should provide migrant health personnel with relevant and accurate information about all health personnel positions that they are offered.” 51% (173) cited recruitment agencies as main source of information. 83% of these said information accurate (14% not accurate), but hidden recruitment charges SCORE:√? But many nurses felt misled about type of work they would do in Ireland! 30% (101) reported: first job was a poor match to their experience and qualification 22 = ‘very poor match’:15 placed in geriatric nursing ‘It was kind of, you’ve been fooled. Because there’s a lot of difference that you worked in a CCU [critical care unit] and then to go and work in geriatrics. It’s nursing as well, but..’ (Sheela). ‘I was hired as a theatre nurse not I will be placed in the elderly later on, you see? We are just like patching the hole, you know, like whatever is lacking... you can go there’ (Regina). I said, you recruited a theatre nurse, that’s why I applied for the post... if you’re not going to... place me in theatre, please send me home tomorrow, because I’m not going to work in the ward... I been working for more than twenty years in theatre’ (Ivory). SCORE:√?? Did the recruiters know? What does it say about the Irish health system?

11. Global Code (3): How we treat them Bullying/Discrimination 55% (184) of respondent migrant nurses reported that they had experienced bullying or discrimination in the workplace. 34% (115) of respondents reported bullying by Irish nursing colleagues and 25% (85) reported bullying by nurse management. 5% (17) had been bullied by NCHDs or consultants. The response to bullying or discrimination varied, but the most popular course of action was to discuss the bullying with colleagues 21% (72), with only 16% (54) of respondents raising the issue with management. Global Code: no explicit protection against bullying Article 4.4:“Migrant health workers (should) enjoy the same legal rights and responsibilities as the domestically trained health workforce in all terms of employment and conditions of work” SCORE: X

12. Global Code(4): Workforce development 5.1: destination countries to work with source countries to promote HR training 5.2: bilateral arrangements to include support to - training and retention in source country - support to ‘return migration’ to source country 5.3: promote professional exchanges, so as to bring benefits to source country SCORE: ?

13. 75% (251) of respondent migrant nurses felt that the recession had impacted on their satisfaction with life in Ireland. Nurses take home pay has been reduced by: Public sector pension levy Increased taxes Reduced availability of overtime Onset of recession and reaction of Irish colleagues had left migrant nurses feeling unsure of their place within the Irish health system: ‘Irish staff made us feel that they don't need migrant nurses any more and that we should start looking for another job because there's no more job and future for us here in Ireland ’ (Respondent 213). Migrant nurses sometimes held responsible by Irish colleagues for Irish health workforce planning decisions, e.g. recruitment embargo. Impact of Recession (2009 data): (1)

14. Impact of Recession: (2) Only 19% (65/337) of respondents planning to remain in Ireland. Citizenship and immigration procedures / obstacles were key factors in determining whether migrant nurses would stay or leave Ireland. Although 80% (269) of respondents held permanent posts within the Irish health system, few have security in their immigration status. Only 7% (23) of respondents had acquired Irish citizenship although 42% (143) have been in Ireland since 2000/2. 8% (28) had become long term residents ‘I am here almost ten years and up to now my status is still uncertain. I fear that if the economy gets worse the Irish government will decide to send us all home. It's very hard to apply/get approved for citizenship, unlike other countries’ (Respondent 121)

15. Onward Migration:do we want them to go? In 2008, 2,146 non-EU migrant nurses sought to have their Irish registration verified, indicating their intent to migrate from Ireland. 2146 represents 19% of the total number of non-EU nurses recruited between 2000 and 2008. Should we want them to stay? These nurses are experienced, specialist nurses, familiar with the Irish health system. They would not be easily replaced either by new graduates or by new international recruits. The loss of 2146 nurses would represent a loss to the health system greater than the annual output from Irish nursing schools We wrote in Dec 2009: “The Irish health system would struggle to cope with the loss of non-EU nurses on such a scale” Or will we recruit and hire new migrant nurses at lower wages??

16. Global Code(3): Workforce sustainability Monitoring the workforce Source and Destination Countries: 5.6: Educate, retain and sustain health workforce appropriate for each country’s needs nurses: we finally began scaling up nurse (degree) training in 2006. by the time the nurses graduated (2009) – no jobs! SCORE: √  X? 6.2:Maintain health personnel information systems 7.3:Designate a National Authority for coordinating activities, producing and exchanging information new HSE-Irish Aid working group (David Weakliam + Síle Fleming) 8.1:Publicise and implement the code 9:Monitor implementation and report to: WHO Secretariat (2012) World Health Assembly (May 2013)

18. Challenges in monitoring workforce movements Immigration Health professions’ councils (nurses, doctors, etc) registration provides a good measure of who arrives, but not where they go subsequently –Health workers move around within the health system (Ireland did not monitor where its foreign nurses went after induction) –Doctors and nurses often stay registered in a country after leaving it, becomes more useful if annual professional registration with a fee Emigration Requests from other countries to professional councils for verifications = a proxy measure of intention to leave (60% act on an intention?) Won’t capture migrant nurses retiring from the profession Recommendation Option A: employers to record minimum data set on new recruitments Option B: use salary payments to track public sector staff – P-Pars?? Ireland (HSE) does not have a workforce strategy and has no system for tracking and monitoring its nurses by specialty / grade

19. Funded by the Health Research Board (2006-10). Research Team (RCSI): Researcher = Dr. Niamh Humphries Principal Investigator = Professor Ruairí Brugha Co-investigator Professor Hannah McGee Publications: http://tinyurl.com/NiamhHumphries Project Contact Details: nhumphries@rcsi.ie, (01) 4022723 Population Health Sciences, Royal College of Surgeons in Ireland Nurse Migration Project