1.8.2007 | Von:
James Stewart
Darlene Clark
Paul F. Clark

Costs and Benefits of Healthcare Worker Mobility

Sending countries

The major costs of the migration of healthcare professionals are borne by the developing countries that lose significant numbers of nurses, physicians and other healthcare professionals.
Geldscheine und Stethoskop (© dpa/ZB)

Healthcare systems in these countries range from barely adequate to completely dysfunctional. They suffer from a host of problems - inadequate funding, inferior technology, epidemics, war and political instability, a lack of infrastructure, insufficient training capacity, and a long-standing shortage of healthcare professionals. The further loss of nurses and physicians to developed countries renders poor healthcare systems even less capable of providing care for their patients.

Thus, one of the most significant cost factors is the source country's diminished ability to provide care for its citizens. The impact is particularly significant when such personnel cannot be replaced because of a shortage. Not only does the healthcare system lose the services of healthcare professionals, but the inability to replace them puts added pressure on the remaining employees. Such pressure further strains the system, creating additional push factors that then contribute to the loss of more healthcare professionals.

Source countries also incur another significant cost when RNs and MDs migrate: their investment in training. The training of healthcare professionals in most developing countries is either entirely sponsored, or heavily subsidised, by the government. This substantial investment in training is lost when a nurse or a physician permanently emigrates to a developed country. The United Nations estimates that each migrating African healthcare professional represents a loss to the source country of US$184,000 [1].

One of the major policy issues complicating efforts to develop an international consensus regarding the employment of migrating healthcare workers is how to compensate countries for lost services and investments. If healthcare workers paid all of the costs of training then there would be little question regarding their right to capture all of the benefits of that training by working in any setting they choose. However, in cases where governments have provided substantial subsidies that enabled future healthcare workers to enrol in educational institutions, the case is not so clear-cut.

The benefits accruing to source countries from the emigration of healthcare workers are twofold: remittances sent home to families and services of migrants who return with enhanced skills and experience. Remittances can have a significant influence on the living standards of the populace in source countries. Collectively, remittances play a crucial role in the economies of many developing nations since these funds represent one of the most important sources of foreign revenue [2]. In the case of the Philippine government, encouragement of the emigration of nurses is a deliberate policy. In support of this policy, nursing schools train many more nurses than their country needs, and those who emigrate become part of a "labour outsourcing industry" driving the Philippine economy. In 2001, expatriate contract workers, including nurses, sent home US$6.2 billion in remittances. The countries employing the greatest number of Filipino nurses are the United States, Ireland, Saudi Arabia and the United Kingdom [3]. In general, however, the Philippine experience appears to be unique and there is scant evidence that remittances compensate for the damage done to healthcare systems in source countries, particularly since remittances go to families, not directly to the healthcare systems.

Source countries can potentially benefit from emigration of healthcare workers in the case of temporary migration. When nurses and physicians leave to work in the healthcare system of a developed country, they gain experience and training in a more advanced setting. In this scenario, migration can be a positive arrangement for a developing country: the source country temporarily gives up its training investment, as well as the healthcare professionals' services; in exchange, upon the nurses' or doctors' return, it recoups its initial investment, as well as the added qualifications and experience gained during the professionals´ time away. Unfortunately for developing countries, there is little evidence that more than a small percentage of emigrants actually return. Even in cases where healthcare workers do return, healthcare systems in developing countries may not be able to take advantage of the skills and expertise acquired abroad. The technologies available in developing countries may be much less sophisticated than those in developed countries, reducing the utility of qualifications and experience obtained overseas.

Receiving countries

While the available evidence suggests that the costs exceed benefits for source countries, benefits tend to exceed costs for receiving countries. There are, in fact, several types of costs incurred by countries hosting immigrant healthcare workers. First, there are costs associated with worker recruitment. The extent to which these costs are shared by employers and government varies from country to country. Such costs are likely to be passed on to consumers and taxpayers. The same can be said for resettlement costs, i.e. temporary support enabling workers to assimilate into a new society such as housing subsidies and public assistance. The UK probably has the most systematic and coordinated recruitment programme of any country in the world. The British National Health Service (NHS) has its own recruitment programme to identify healthcare professionals interested in immigrating to the UK. It operates different recruitment strategies for the various professions. It usually recruits physicians on an individual basis, but tends to recruit nurses in groups of ten, twenty, or more from a specific country. As part of its recruitment process, the NHS provides information on job locations, living arrangements and immigration procedures [4].

Some critics argue that the immigration of highly trained healthcare workers is linked to the erosion of employment conditions among domestic healthcare workers. For example, if immigrant workers are more willing to accept part-time and contractual positions than domestic workers, the wages and employment conditions of domestic workers are adversely affected. One negative outcome is lower tax receipts from domestic workers than would otherwise be the case. Although diminished worker commitment and associated negative effects on productivity would have the greatest impact at the firm level, the macro-economic implications should not be overlooked. As a final example, it is important to recognise that there may also be adverse effects on the quality of healthcare provided to citizens in the receiving country if immigrant workers are imperfect substitutes for domestic workers.

The benefits accruing to receiving countries from the inflow of healthcare workers are manifold. The most direct benefit is the reduction in the shortage of skilled healthcare workers plaguing developed countries. Given that the healthcare systems in these countries still face a shortage, the situation would clearly be even worse without these foreign workers. The quality of healthcare available to consumers will be improved compared to a scenario in which shortages are greater, and public health risks will be reduced as well. If the employment of immigrant healthcare professionals depresses wages of workers in the healthcare sector, consumers could conceivably benefit financially if any of the reductions in labour costs are passed through in the form of lower prices (or taxes). Receiving countries will also benefit from taxes paid by immigrant healthcare workers. In addition, the recruitment of immigrant healthcare workers can allow local communities with a shortage of domestic healthcare workers to remain competitive in efforts to attract new employers, with the potential positive impact of increased local tax revenues.

Costs and Benefits in Sending and Receiving Countries
Sending countriesReceiving countries
  • Reduction in domestic health care delivery capacity
  • Loss of training investments in emigration professionals
  • Loss of consumption and tax receipts
  • Decline in morale and commitment among remaining workers
  • Recruitment costs
  • Resettlement costs
  • Decline in compensation and working conditions of domestic workers
  • Decline in morale and commitment among domestic workers
  • Reduction in tax receipts from domestic workers
  • Benefits
  • Remittances received from expatriates
  • Improvements in skills of returners
  • Relief of supply shortages
  • Improved quality of health care
  • Tax receipts from foreign workers
  • Enhanced local competitiveness
  • Source:Author's summary


    See Oyowe (1996).
    See Forcier, Simoens and Giuffrida (2004). For more information on remittances, see "Remittances – A Bridge between Migration and Development?" focus Migration Policy Brief No. 5).
    See Diamond, D. (2002): "One nation, overseas." Wired Magazine, June, online edition.
    See Buchan and Dovlo (2004); Buchan, Jobanputra and Gough (2004).



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