Debates over circular migration to fill employment gaps in industrialised economies are of particular relevance to the health sector, where demographic change and concurrant increases in chronic diseases and multiple morbidities are driving an ever-greater need for qualified health professionals. However, a fine balance needs to be struck between migrants’ individual aspirations and the impact of their migration decision on health systems already hit by the effects of the crisis and austerity measures. What role can circular migration play in achieving ethical recruitment and health system sustainability?
’’Circular migration: Silver bullet or placebo solution?’’ was the apt title of a conference organised by the Gesellschaft fuer Internationale Zusammenarbeit (GIZ) on 26 November. The event drew attention to the fact that not only will there be massive shortages of health personnel in upcoming decades, with official estimates ranging between one and two million by 2020, but overall the EU employment market might experience a shortage of about 50 million qualified workers by 2030, hence putting migration once again at the centre of policy debates over how to achieve international economic, employment, development and health goals.
As EPHA has highlighted in its advocacy work on the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel (see the EPHA Briefing on the WHO Code), circular migration represents one option of filling acute shortages on a short or longer-term basis. By definition, circular migration only applies for positions ranging from 6 months to 5 years in length. Sometimes it is claimed that circular migration can bring about a ’’triple win’’ - for home countries in the form of remittances sent by migrants; the transfer of knowledge and skills, for receiving countries in the form of flexible labour; and for migrants through new experiences, professional development and higher salaries earned abroad.
However, as EPHA has also underlined, the reality is more complex and health worker migration is in itself a symptom of flaws in health systems. Paradoxically, even countries relying strongly on international health workers, both from within and outside of the EU, often experience simultaneous outflows of qualified doctors and nurses in search of higher salaries and better working conditions, as has been the case in the U.K. and in Germany. At the same time, health worker migration from poor countries, including the ’’new’’ Member States of Romania and Bulgaria, is causing severe shortages, especially in rural and peripheral regions. Especially Romanian practitioners and nurses have left the country in their thousands, thereby threatening the (self)sustainability of the health system.
Moreover, the ’’wins’’ for migrants and their sending countries are debatable: regular back-and-forth migration brings social consequences, remittances are usually only high enough in relatively well paid positions, and in any case such programmes are usually not open to those most in need of circular migration, i.e. the poorest. In fact even the gains for receiving countries are not straightforward given that international workers will require adaptation and training, especially regarding languages, in order not to compromise patient safety.
The ideal of a sustainable migration management system in the context of health was addressed in a panel discussion including, inter alia, Professor Ronald Skeldon of the University of Sussex, Camilla Hagstrom, team leader at DG DEVCO at the European Commission, and EPHA Policy Coordinator for Health Systems Sascha Marschang. The discussion followed a short film about a pilot project deploying Bosnian nurses in a Frankfurt hospital which proved to be a very successful model for circular migration.
EPHA underlined that migration is a complex phenomenon that does not easily lend itself to a ’’one size fits all’’ solution given the differing economic and cultural contexts of both home and host countries. Should temporary migrants fill permanent jobs? If circular migration programmes are to succeed, they need not only to be well managed, comprehensive and fair - offering equal treatment of temporary workers in terms of working conditions and salaries, as well as adequate pre- and post-migration support - but flexible, to stop circular migrants turning into undocumented migrants as a result of personal life changes, thereby losing residency and healthcare rights. Moreover, recruitment must be transparent and inclusive, and intermediary agencies must be regulated to avoid exploitation of would-be migrants and bypassing of international minimum labour standards. Most of all, the aspirations of migrants need to be taken into account so that they do not become disposable labour without rights. It will also be important to avoid the mistakes made in Europe during the guest worker schemes of previous decades.
While circular migration programmes will probably become more common in the years to come, they are not sufficient to address the larger challenges of health systems both in Europe and in the global south: the need to invest in, train and retain qualified health workers with the ultimate goal of self-sustainability. There is therefore a strong need to explore other types of instruments to strenghten health system in sending countries (see also the policy recommendations of Action for Global Health), and ’’upgrading’’ circular migrants should they wish to remain in their host countries or move on to a third country. Ultimately Europe needs to harness its wealth and expertise to enable ’’brain circulation’’ while at the same time creating incentives for health workers to remain where their education and impact will be most relevant, be that in their home countries or their countries of education/training.
EPHA emphasises that the full implementation of the WHO Global Code of Practice is one crucial element in moving towards the desired ’’triple win’’, which will nonetheless remain an illusion given the extent of global (health) inequalities. At EU level, it is equally important to support the implemention of the Action Plan on the EU Health Workforce, which calls for strengthening health systems, better data collection and actions to improve training and retention of health workers.
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