Taking More Than a Fair Share? The Migration of Health Professionals from Poor to Rich Countries

The international migration of health workers, especially of physicians and nurses but also increasingly of other health workers, has become a major global health concern. Recent meetings, such as the World Health Assembly of 2004 [1] and the High-Level Forum on the Millennium Development Goals in December 2004, as well as a number of publications have highlighted the severe shortage of health personnel in poorer parts of the world and the rise in demand for health workers in rich countries. The 2005 World Health Assembly, being held this month, is expected to discuss how to limit the adverse effects of the migration and to promote fairer recruitment tactics by developed countries as a follow-up to a resolution passed in 2004. There is now considerable interest in measuring and managing the migratory fl ow of health workers; in seeking reparations, payments or remittances; and in training " substitute health workers " —groups who have taken on jobs, functions, and roles that are normally the tasks of internationally recognized professionals such as doctors, nurses, and pharmacists [2]. Indeed, words such as " slavery " and " human rights " underlie the debate's emotional underpinnings (such words have appeared, for example, in listserv discussions about health worker migration). Though some migration occurs between rich countries (and also between poor countries), most of the migration of health professionals is occurring from countries with physician densities of about 17 per 100,000 population to countries with densities of 300 per 100,000 population (see p. 16 of [3]). This is a good example of the " inverse care law " —that countries that need the most health care resources are getting the least (Figure 1). Why does this migration occur when there appears to be a glut of physicians in the recipient countries? One of the reasons is that pay levels are up to 24 times higher in recipient countries than they are in source countries [4]. Countries such as India, the Philippines, and Nigeria—highly populated countries that train large numbers of health professionals and have a long-standing remittance culture, in which professionals working outside the country send money back home to relatives—have produced doctors and nurses for " export. " However, demand for different kinds of health professionals can fl uctuate. For example, recent rises in demand for nurses in the United States led to reports of immigrant doctors in Florida who took up nursing to …