Workers Movement: the Push-Pull Factor

28 February 2007 (Last Updated February 28th, 2007 18:30)

Analysis of the issues surrounding health worker migration often boils down to a question of ‘brain drain or brain gain’. Professor James Buchan reviews the main policy implications for so-called source countries and destination countries involved in active recruitment.

The issue of migration of health professionals has become a significant feature of health policy debate, featuring prominently in dialogue at the World Health Assembly. The World Health Report in 2006, like several commentators, highlighted the damaging impact of international recruitment on the health systems of some of the main ‘source’ countries, particularly in sub-Saharan Africa. For hospital employers and others in some developed countries, active international recruitment has become a ‘solution’ to health professional skill shortages. However, a solution for one country may become a problem for another.

Migration of health workers is sometimes presented as a one-way, linear ‘brain drain’, but the dynamics of international mobility, migration and recruitment of health workers are more complex than that.

They cover issues of individual choice, motivations and attitudes to career development; the variable impact of push and pull factors stimulating migration; the relative status of health workers in different systems; the differing approaches of national governments to managing, facilitating or attempting to limit the outflow or the inflow of migrants; and the role of recruitment agencies as intermediaries in the process.


There is continued debate about the various potential positive and negative effects of migration of doctors, nurses and other key staff, particularly from developing countries. There are push factors, stimulating workers to consider leaving their country of residence, and there are pull factors exerted by destination countries, making them more attractive places to live and work.

To an extent there is a ‘mirror image’ of push and pull, related to the relative levels of pay, career prospects, working conditions and environments available in the source and destination countries. Where the relative gap (or perceived gap) is particularly significant, the pull of the destination country will be felt.

However, there are other push factors in some countries, such as the impact of HIV/AIDS on health system workers, concerns about personal security in areas of conflict, and economic instability.

Other pull factors, such as the opportunity to travel or to assist in aid work, will also be significant for some individual health workers.


Some national governments and government agencies, such as in the Philippines, are attempting to encourage outflow of health workers from their country. This may have a financial imperative (to encourage the generation of remittance income), it may be a response to labour market over-supply, or it may be an attempt to develop a long-term improvement in the skills base of the workforce by encouraging short-term outflow to other countries where training is available.

"Destination countries have failed to 'grow their own' and 'keep their own' health workers in sufficient numbers, and have used the quick fix of international recruitment."

For most source countries, however, outflow of doctors, nurses and other health workers is a problem rather than a policy initiative. The unplanned and unmanaged outflow of scarce health workers is having a negative impact on health system effectiveness and is directly affecting patient care. Hospitals and facilities are under-staffed, scarce and relatively expensive skilled staff are reduced in number, and the workload of remaining staff can increase to unmanageable levels.

Some countries have initiated policy responses to attempt to reduce outflow, including "bonding" health professionals to home-based employment for a specified period of time after completion of training. This may not be effective if compliance is not monitored or if there is scope to "buy out" of the bond.

Preventing workers from leaving through the use of monetary or regulatory barriers is one policy response, but it does nothing to address the push factors which have been the reason for stimulating the workers’ desire to leave. It also cuts across principles of free mobility of individuals.

Other policy responses to reducing outflow relate to a more direct attempt to reduce push factors, through addressing issues of poor pay and career prospects, poor working conditions, high workloads, responding to concerns about security and improving educational opportunities, and so forth. Clearly there is a financial cost involved in such initiatives, but all national governments must be confident that health workers are receiving fair and equitable treatment within existing financial constraints.

Another policy response is to recognise that outflow cannot be halted where principles of individual freedom are to be upheld, but to then work at ensuring such outflow that does occur is managed and moderated.

The nurse "managed migration" initiative being undertaken in the Caribbean is one example of coordinated intervention to attempt to minimise the negative impacts of outflow while looking to secure at least some benefit from the process.

Some countries in Africa are also examining the options of training health workers who do not have internationally recognized qualifications, on the basis that these staff are less likely to be internationally recruited. Examples can be found among mid-level or "substitute" health workers in Ghana, Malawi, Mozambique, Tanzania and Zambia.


There has been recent lobbying by the Medical Associations in the UK and Canada, among others, requiring developed countries to become more self-sufficient in meeting their health workforce needs. These organisations have pointed to the need for the relatively rich countries of the developed world to adopt a more ethical position, taking responsibility for sourcing their own workforce requirements, rather than using the "quick-fix" (and relatively low-cost) option of recruiting from the developing world.

A second policy challenge for destination countries is the efficiency challenge. If there is an inflow of health workers recruited from source countries, how can this inflow be moderated and facilitated to make an effective contribution to the health system? Some destination countries have developed a policy response to attempt to manage the ethical-efficiency balance. The Departments of Health in the Republic of Ireland, England and Scotland have initiated "ethical" guidelines for public sector employers recruiting health professionals from other countries.

Policy responses include: improving the regulatory or certification process to enable these workers to obtain registration more easily; "fast-tracking" their visa or work permit applications; developing coordinated multi-employer approaches to recruitment; developing multi-agency approaches to coordinated placement; and (where necessary) providing initial periods of supervised practice or adaptation as well as language training, cultural orientation and social support.

Another critical aspect of the ethical view of international recruitment is that the recruits should receive fair treatment and equal opportunities at work and in the society of the destination country. There have been many accounts of recruits being misled about the level of salary, career prospects and accommodation that will be available in the destination country, and others are discriminated against when they arrive. Some recruitment agencies act ethically in their practices, but others have been reported as exploiting the health workers that they are responsible for recruiting.

These points are highlighted in the only international country-based code for foreign health workers – that agreed by the 53 countries of the British Commonwealth in 2003, the Code of Practice for the International Recruitment of Health Workers.


The main driver for the current high level of international recruitment activity is skills shortages in some developed countries. These destination countries have failed to "grow their own" and "keep their own" health workers in sufficient numbers, and have used the quick fix of international recruitment, exploiting the existence of push factors, by exerting a pull of better salaries and conditions of employment. As such, health worker migration can often be a symptom of deeper problems in workforce planning, in either the source or the destination country, or both.

"For hospital employers and others in some developed countries, active international recruitment has become a ‘solution’ to health professional skill shortages."

If national governments and international agencies wish to actively engage in harnessing these dynamics more effectively, they have three basic options. One option is to support improvements in pay, working conditions and other initiatives to assist retention of health workers.

For example, the UK Department for International Development (DFID) is currently supporting pay rises for health workers in Malawi as an attempt to improve retention. In many cases, it is likely that more workers would prefer to stay in their home country if their quality of life were at least adequate.

They could also encourage and facilitate bilateral managed or regulated flows of nurses, doctors and other staff. In addition, they could institute some arrangement whereby compensation flows from the recruiting country back to the source country. This compensation could be directly or indirectly financial, as part of a donor package, through educational support, or in the form of a return flow of better-trained staff. This latter issue is controversial and continues to be debated.

Push factors of low pay and relatively limited career opportunities for healthcare professionals will continue to have an impact in many developing countries, just as pull factors related to skills shortages will persist in many developed countries. The debate on health worker migration must shift from an obsession with numbers (how many?) to identifying effective approaches to managing and moderating the process (how?).

There are also more fundamental issues to address. While migration of health workers is often characterised as a problem, it can also be a symptom of a deeper malaise in the HR component of health systems: workforce planning failures; inability (or unwillingness) to pay fairly; and lack of career prospects. Migration of health workers should not be addressed in isolation – it has to be assessed as an integral part of the overall dynamics of the healthcare labour market, both nationally and globally.