Barriers to Movement of Health
Professionals
A Case Study of India
Stakeholders’ Consultation Meeting
New Delhi
Presentation By
Pranav Kumar
CUTS International, India
pk@cuts.org
Objective of the Study
To identify barriers faced by Indian healthcare
professionals in select countries
Based on identification of barriers the issues which
India can prioritise in the ongoing GATS
negotiations
To analyse the historical and contemporary trend of
migration of healthcare professionals from India
To highlight the growing importance of trade in
health services in the recent years
Ways to increase the export of health services
under Mode 4 without jeopardising the domestic
health services
Coverage of the Study
Int. migration of health professionals – historical
and contemporary trend
Migration of Indian health professionals
Trade in health services, its impact on home cty
Migration of Indian health professionals – main
destinations
Major procedural requirements in host country
Major administrative and procedural barriers
Health services under GATS
Stakeholders’ perception
Policy recommendations
Methodology and Limitation
Largely based on secondary data and information
sources
Information drawn mainly from the government
regulatory agencies of host countries
Information also collected through stakeholders’
perception survey (qualitative) in select cities of India
Based on contemporary economic thoughts
Lack of credible data on trade in health services
Migration and other data were taken from WHO,
IOM, OECD, WTO and GoI
In India BoP account has no separate category of
health services; no sectoral classification of
remittances receipts under this category
Study covers only doctors and nurses and developed
countries’ destinations
International Migration of
Health Professionals
Main Features:
Health professionals make up a small proportion of all migrating
professionals
The international migration of health workers is mainly taking
place from North to North and South to North
South-South migration - there are few instances such as Indian
doctors and nurses migrating to Gulf countries
India and Pakistan from South Asia, Philippines from SouthEast Asia, South Africa, Nigeria and Ghana from Africa are the
major source countries
India and the Philippines are systematically trying to produce
surplus nurses and medical doctors for export to developed
countries
African countries are facing acute crisis in the domestic delivery
of health services because of loss of health human resources to
developed countries
Table 1: Physician Flows in 1972
Stock
Inflow
Outflow
Change
Countries
Developed 1,746,000
118,000
52,300
65,700
Developing 615,300
Totals
2,361,300
14,300
261,000
67,100
119,400
-52,800
Source: Mejia and Pizurki, 1976
International Migration
Contemporary Trend
Main Features:
Marred by controversy over unethical
recruitment by developed countries
Nurses dominate the current migration as
OECD countries face severe shortage of nurses
Southern doctors continue to migrate to North
for higher education and research opportunities
While India is the lead source of doctors, the
Philippines continue to dominate in nurses
Table 2: Doctors and Nurses Trained Abroad Working in OECD
Countries (Source: WHO)
OECD
Country
Doctors Trained Abroad
Number
Nurses Trained Abroad
% of Total
Number
% of Total
Australia
11,122
21
NA
NA
Canada
13,620
23
19,061
6
Finland
1,003
9
140
0
France
11,269
6
NA
NA
Germany
17,318
6
26,284
3
NA
NA
8,758
14
New Zealand
2,832
34
10,616
21
Portugal
1,258
4
NA
NA
United
Kingdom
69,813
33
65,000
10
213,331
27
99,456
5
Ireland
United States
Table 3: Destination Countries:
Total No. of Nurses and Sources of International
Recruitment, 2001
No. of Nurses
Source Country of Recruitment
Australia
149,202
UK, New Zealand
Ireland
61,629
UK, Philippines, South Africa
Norway
45,133
Scandinavian countries, Germany,
Philippines
United
Kingdom
640,000
(580,000)
Philippines, South Africa, Australia
United States
2,238,800
Philippines, Canada, S. Africa and
Nigeria
Country
Source: OECD Health Data CD-ROM, 2001 as given in report,
“International Nurse Mobility: Trends and Policy Implications,
WHO, International Council of Nurses and Royal College of
Nursing, 2003
Table 4: Main Push and Pull Factors in International Nursing
Recruitment
Push Factors
Pull Factors
Low pay (absolute and/or relative)
Poor working conditions
Lack of resources to work
effectively
Limited career opportunities
Limited educational opportunities
Impact of HIV/AIDS
Unstable/dangerous work
environment
Economic instability
Higher pay (remittances
opportunities)
Better working conditions
Better resourced health systems
Career opportunities
Provision of post-basic education
Political stability
Travel opportunities
Aid work
Source: “International Nurse Mobility: Trends and Policy Implications”, WHO, International
Council of Nurses and Royal College of Nursing, 2003
Migration of Indian Health
Professionals
India is the largest source country of physicians
to four major recipients – USA, UK, Canada
and Australia
The US and the UK remained the main
destinations of Indian nurses
In fact, in UK, India has surpassed Philippines
in terms of annual registration of nurses
The US hospital, however, is still dominated by
Filipino nurses
IMGs (International Medical Graduates) in the Physician
Workforces of the Four Major Recipient Countries: The Share of
India
United States
United Kingdom
Source Country
No. of IMGs
workforce)
(%
of Source Country
India (Rank 1)
40,838 (4.9)
India (Rank 1)
15,093 (10.9)
Philippines
17,873 (2.1)
Ireland
2,845 (2.1)
Pakistan
9,667 (1.2)
Pakistan
2,693 (1.9)
Canada
No. of IMGs
workforce)
(%
of
(%
of
Australia
Source Country
No. of IMGs
workforce)
(%
of Source Country
No. of IMGs
workforce)
United
Kingdom
2,735 (4.0)
United Kingdom 4,664 (8.6)
South Africa
1,754 (2.6)
India (Rank 2)
2,143 (4.0)
India (Rank 3)
1,449 (2.1)
New Zealand
1,742 (3.2)
Overseas-trained Nurses Registered per annum in the UK 19982004-05
Country
1998- 199999
00
200001
200102
200203
200304
200405
Philippines
52
1052
3396
7235
5594
4338
2521
India
30
96
289
994
1833
3073
3690
S. Africa
599
1460
1086
2114
1480
1689
933
Australia
1335
1209
1046
1342
940
1326
981
179
208
347
432
524
511
466
Nigeria
Source: Nursing and Midwifery Council (NMC). www.nmc-uk.org
Trends of Nurses Supply to UK by Select Developing
Countries
8000
7000
6000
5000
4000
3000
2000
1000
0
1998-99
1999-00
Philippines
2000-01
India
2001-02
S. Africa
2002-03
2003-04
Australia
2004-05
Nigeria
Foreign Educated Nurses in USA (in Percentage)
Country
Philippines
Canada
United Kingdom
Nigeria
Ireland
India
2000
43
2004
50.2
16
8
20.2
8.4
2.3
10
1.5
1.3
Source: Health Resources and Services Administration, US Department
of Health and Human Services.
Trade in Health Services
Unlike general pattern of world trade in services
health services trade takes place mainly
through mode 4 and mode 2
Health services constitute a very low share in
total world trade in services
There is a serious dearth of data on trade in
health services
Neither WTO nor the individual member has
separate classification of health services
Some data is available on health tourism and
medical outsourcing
Migration of Health Professionals:
The Impact on Home country
Neo-classical versus Neo-liberal thoughts
Caused a massive shortage of healthcare
workers in many African countries
While WHO recommends a minimum of 100
nurses and 20 doctors per 100,000 people,
many sub-Saharan African countries have
fewer than recommended numbers
The situation is somewhat different in India,
Philippines and China
Migration of Health
Professionals: Impact on India
Going by the WHO recommended minimum standards India does
fulfill in doctors but trailing far behind in case nurses availability.
In 2004 there were 62 nurses and 51 doctors per 100,000 people
available in India
Impact could also be measured through inflow of remittances and
locals preference for medical and nursing professions
RBI has reported that Indians living abroad transferred $24.6bn in
fiscal year 2005-2006
The country has 242 medical colleges, 205 BDS colleges and 67
MDS colleges in 2005-06
The admissions to medical colleges increased from 11,800
admissions per year in 1990 to 24,000 in 2005
In keeping with the rising demand in developed countries, the
government-aided as well as private Indian universities churn out
30,000 nurses a year (three times of 1990s)
Nursing Colleges are finding it difficult to fill vacancies, be it a principal’s
position, lecturer’s or a tutor’s
Procedural Requirements in
Major Destination countries
For Doctors (In USA)
Federation Licensing Examination (FLEX) or its equivalent as
determined by the US Dept. of Health and human Services
License or other authorisation required by the state of
intended employment to practice medicine
Coming to the US primarily to teach or conduct research, or
both, for a public or a nonprofit private educational or
research institution or agency, and that no patient care will be
performed, except that which is incidental to the teaching or
research
Must qualify the English proficiency test conducted by the
Educational Commission for Foreign Medical Graduates
(ECFMG).
Contd.
For Doctors (in UK)
Foreign doctors from outside the EU must be
registered with the UK General Medical Council
(GMC)
The doctor is required to pass the examinations as set
out by the Professional and Linguistic Assessment
Board (PLAB)
must be proficient in the English language. This would
be demonstrated by obtaining the relevant scores in
the IELTS test (a minimum of 7 as an overall score)
must have at least 12 months' postgraduate clinical
experience in a teaching hospital, or another hospital
approved by the medical registration authorities in the
appropriate country
Contd.
For Doctors (in Australia)
Satisfy Australian Medical Council (AMC) English
language proficiency requirements.
General practitioners (GPs/family physicians) must
pass the AMC exam
Before commencing work as general practitioner the
physician need to have his general practice
qualifications and experience assessed by the Royal
Australian College of General Practitioners
Hospital non-specialists must meet the specific
registration requirements of the relevant State or
Territory Medical Board for an Area of Need position.
Specialists must apply to the relevant Specialist
Medical College for recognition as a specialist via the
Contd.
For Doctors (in Canada)
to apply for Licensure of the Medical Council of Canada
(LMCC), a graduate must have passed both Medical Council of
Canada Qualifying Examination Parts one and two (MCCQE
Parts I and II)
As a pre-requisite to sitting for the MCCQE Part I, an
International medical graduate must pass the Medical Council
of Canada Evaluating Examination (MCCEE)
The university granting the degree must be listed in either the
WHO World Directory of Medical Schools or the FAIMER
International Medical Education Directory
In most provinces, graduates of foreign medical schools are
required to have two to six years of postgraduate medical
training at a Canadian university and must pass the appropriate
certification examinations of the College of Family Physicians of
Canada or the Royal College of Physicians and Surgeons of
Canada
Contd.
For Nurses (in USA)
A diploma from a nursing school in her country;
An RN license in her country;
A full and unrestricted license to practice professional
nursing in the state of intended employment, and/or a
certification issued by the Commission on Graduates
of Foreign Nursing Schools (CGFNS),
Evidence that she has passed the NCLEX-RN
licensing examination
she must achieve a certain minimum score on tests in
written and spoken English administered by TOEFL,
or IELTS or the TOEIC
Contd.
For Nurses (in UK)
Overseas nurses must be registered with the UK
Nursing and Midwifery Council (NMC) in order to
practice nursing in the UK
The programme of education and training must have
been of three years or 4600 hours in length
This programme must have been carried out at a postsecondary school level of education
Also the programme must have demonstrated a
balance of theory and practice
Must have a reasonable command of the English
language. This would be demonstrated by obtaining
the relevant scores in the IELTS test (a minimum of 7
as an overall score)
Contd.
For Nurses (in Australia)
Applicants possess a certificate, diploma or degree in nursing
issued by the educational institution where the course in nursing
was undertaken.
Applicants possess documentation evidencing registration issued
by the jurisdiction where the nursing course was completed.
Applicants have completed an education program leading to
registration as a nurse, which is assessed by the Australian nurse
regulatory authorities as meeting the requirements for registration,
including competence.
Applicants are registered in the country of most recent practice and
the relevant regulatory authority verifies this. Dates of employment
and professional competence are confirmed by recent employers.
Applicants are successful in an acceptable English language test
endorsed by the ANC. There are two tests that can be taken.
These are: International English Language Testing System (IELTS)
and occupational English Test (OET) for Nurses
Contd.
For Nurses (in Canada)
Completion of a Nursing Education program of minimum 3
years (4 years required in Ontario).
A minimum of 5 years postgraduate experience, preferably in
ICU, CCU, OR, ER or L&D.
Good character - based on references, no record of outstanding
criminal charges or convictions relevant to the practice of
Nursing.
Fitness to engage in the practice of Nursing - based on
satisfactory employment references, registration in good
standing in other jurisdictions and no health problems that
impair ability to practice.
Fluency in English; if native language is not English, passing
scores at: TOEFL Paper=550/Computer=213 and TSE=50; or
Academic IELTS: At least 7 in Speaking and 6.5 for Writing,
Listening and Reading.
Barriers
Multiplicity of qualification and licensing
requirements – more stringent and complex in
US and Canada
Wage parity requirement as a pre-condition for
labour market tests
Economic Needs Tests
“Foreign Labour Certification” of US
 “Area of Need” in Australia
 “Labour Market Opinion” in Canada

Economic Needs Test less stringent for nurses
Complex and time consuming visa procedures
Some Observations
For nurses US is the preferred destination but
they face most stringent qualification barriers
Visa procedures for nurses are more complex
for nurses in the US
ENTs are however relatively liberal for nurses in
USA, Australia and UK
Negotiating MRAs is a big challenge particularly
with larger federal countries like the US and
Canada
UK is by and large more liberal for Indian health
professionals