Rich Countries Lure Health Workers From Low-Income Nations to Fight Shortages

The costs to source countries:

There are few nurses in the Zambian capital with the skills and experience of Alex Mulumba, who works in the operating room at a critical care hospital. But he has recently learned, through a barrage of social media posts and LinkedIn solicitations, that many faraway places are eager for his expertise, too — and will pay him far more than the $415 per month (including an $8 health risk bonus) he earns now.

Mr. Mulumba, 31, is considering those options, particularly Canada, where friends of his have immigrated and quickly found work. “You have to build something with your life,” he said.

Canada is among numerous wealthy nations, including the United States and United Kingdom, that are aggressively recruitingmedical workers from the developing world to replenish a health care work force drastically depleted by the Covid-19 pandemic. The urgency and strong pull from high-income nations — including countries like Germany and Finland, which had not previously recruited health workers from abroad — has upended migration patterns and raised new questions about the ethics of recruitment from countries with weak health systems during a pandemic.

“We have absolutely seen an increase in international migration,” said Howard Catton, the chief executive of the International Council of Nurses. But, he added, “The high, high risk is that you are recruiting nurses from countries that can least afford to lose their nurses.”

About 1,000 nurses are arriving in the United States each month from African nations, the Philippines and the Caribbean, said Sinead Carbery, president of O’Grady Peyton International, an international recruiting firm. While the United States has long drawn nurses from abroad, she said demand from American health care facilities is the highest she’s seen in three decades. There are an estimated 10,000 foreign nurses with U.S. job offers on waiting lists for interviews at American embassies around the world for the required visas.

Since the middle of 2020, the number of international nurses registering to practice in the United Kingdom has swelled, “pointing toward this year being the highest in the last 30 years in terms of numbers,” said James Buchan, a senior fellow with the Health Foundation, a British charity, who advises the World Health Organization and national governments on health worker mobility.

“There are 15 nurses in my unit and half have an application in process to work abroad,” said Mike Noveda, a senior neonatal nurse in the Philippines who has been temporarily reassigned to run Covid wards in a major hospital in Manila. “In six months, they will have left.”

As the pandemic enters its third year and infections from the Omicron variant surge around the world, the shortage of health workers is a growing concern just about everywhere. As many as 180,000 have died of Covid, according to the W.H.O. Others have burned out or quit in frustration over factors such as a lack of personal protective equipment. About 20 percent in the United States have left their jobs during the pandemic. The W.H.O. has recorded strikes and other labor action by health workers in more than 80 countries in the past year — the amount that would normally be seen in a decade. In both developing countries and wealthy ones, the depletion of the health work force has come at a cost to patient care.

European and North American countries have created dedicated immigration fast-tracks for health care workers, and have expedited processes to recognize foreign qualifications.

The British government introduced a “health and care visa”program in 2020, which targets and fast tracks foreign health care workers to fill staffing vacancies. The program includes benefits such as reduced visa costs and quicker processing.

Canada has eased language requirements for residency and has expedited the process of recognizing the qualifications of foreign-trained nurses. Japan is offering a pathway to residency for temporary aged-care workers. Germany is allowing foreign-trained doctors to move directly into assistant physician positions.

In 2010, the member states of the W.H.O. adopted a Global Code of Practice on the International Recruitment of Health Personnel, driven in part by an exodus of nurses and doctors from nations in sub-Saharan Africa ravaged by AIDS. African governments expressed frustration that their universities were producing doctors and nurses educated with public funds who were being lured away to the United States and Britain as soon as they were fully trained, for salaries their home countries could never hope to match.

The code recognizes the right of individuals to migrate but calls for wealthy nations to recruit through bilateral agreements, with the involvement of the health ministry in the country of origin.

In exchange for an organized recruitment of health workers, the destination country should supply support for health care initiatives designated by the source country. Destination countries are also supposed to offer “learn and return” in which health workers with new skills return home after a period of time.

But Mr. Catton, of the international nurses organization, said that was not the current pattern. “For nurses who are recruited, there is no intention for them to go back, often quite the opposite: They want to establish themselves in another country and bring their families to join them,” he said.

Zambia has an excess of nurses, on paper — thousands of graduates of nursing schools are unemployed, although a new government has pledged to hire 11,200 health workers this year. But it is veteran nurses such as Lillian Mwape, the director of nursing at the hospital where Mr. Mulumba works, who are most sought by recruiters.

“People are leaving constantly,” said Ms. Mwape, whose inbox is flooded with emails from recruiters letting her know how quickly she can get a visa to the United States.

The net effect, she said, “is that we are handicapped.”

“It is the most-skilled nurses that we lose and you can’t replace them,” Ms. Mwape said. “Now in the I.C.U. we might have four or five trained critical-care nurses, where we should have 20. The rest are general nurses, and they can’t handle the burden of Covid.”

Dr. Brian Sampa, a general practitioner in Lusaka, recently began the language testing that is the first step to emigrate to the United Kingdom. He is the head of a doctor’s union and vividly aware of how valuable physicians are in Zambia. There are fewer than 2,000 doctors working in the public sector — on which the vast majority of people are reliant — and 5,000 doctors in the entire country, he said. That works out to one doctor per 12,000 people; the W.H.O. recommends a minimum of one per 1,000.

Twenty Zambian doctors have died of Covid. In Dr. Sampa’s last job, he was the sole doctor in a district with 80,000 people, and he often spent close to 24 hours at a time in the operating theater doing emergency surgeries, he said.

The pandemic has left him dispirited about Zambia’s health system. He described days treating critically ill Covid patients when he searched a whole hospital to find only a single C-clamp needed to run oxygenation equipment. He earns slightly less than $1000 a month.

“Obviously, there are more pros to leaving than staying,” Dr. Sampa said. “So for those of us who are staying, it is just because there are things holding us, but not because we are comfortable where we are.”

The migration of health care workers — often from low-income nations to high-income ones — was growing well before the pandemic; it had increased 60 percent in the decade to 2016, said Dr. Giorgio Cometto, an expert on health work force issues who works with the W.H.O.

The Philippines and India have deliberately overproduced nurses for years with the intention of sending them abroad to earn and send remittances; nurses from these two countries make up almost the entire work force of some Persian Gulf States. But now the Philippines is reporting shortages domestically. Mr. Noveda, the nurse in Manila, said his colleagues, exhausted by pandemic demands that have required frequent 24-hour shifts, were applying to leave in record numbers.

Yet movement across borders has been more complicated during the pandemic, and immigration processes have slowed significantly, leaving many workers, and prospective employers, in limbo.

While some countries are sincere about bilateral agreements, that isn’t the only level at which recruitment happens. “What we hear time and time again is that recruitment agencies pitch up in-country and talk directly to the nurses offering very attractive packages,” Mr. Catton said.

The United Kingdom has a “red list” of countries with fragile health systems from which it won’t recruit for its National Health Service. But some health workers get around that by entering Britain first with a placement through an agency that staffs private nursing homes, for example. Then, once they are established in Britain, they move over to the N.H.S., which pays better.

Michael Clemens, an expert on international migration from developing countries at the Center for Global Development in Washington, said the growing alarm about outflows of health workers from developing countries risks ignoring the rights of individuals.

“Offering someone a life-changing career opportunity for themselves, something that can make a huge difference to their kids, is not an ethical crime,” he said. “It is an action with complex consequences.”

The United Kingdom went into the pandemic with one in 10 nurse jobs vacant. Mr. Catton said it some countries are making overseas recruitment a core part of their staffing strategies, and not just using it as a pandemic stopgap. If that’s the plan, he said, then recruiting countries must more assiduously monitor the impact on the source country and calculate the cost being borne by the country that trains those nurses.

Alex Mulumba, the Zambian operating room nurse, says that if he goes to Canada, he won’t stay permanently, just five or six years to save up some money. He won’t bring his family with him, because he wants to keep his ties to home.

“This is my country, and I have to try to do something about it,” he said.

Source: Rich Countries Lure Health Workers From Low-Income Nations to Fight Shortages

Canada has a big-time nursing shortage. So why can’t these two fully certified nurses get the OK to practise?

Of note, along with the backlog numbers for the various programs:

A former intensive-care nurse in the Philippines, Katrina Deauna has watched from the sidelines as Ontario — and all of Canada — struggles with chronic nursing shortages laid bare by the pandemic.

While the foreign caregiver enjoys looking after the 18-month-old baby girl and six-year-old son of her Canadian employer, she says, she would rather use her front-line nursing skills and experience to help those fighting for their lives against COVID-19.

Deauna has met all the licensing requirements of the Ontario College of Nursing. All she is missing is the authorization to work — either through a letter that confirms she’s eligible for permanent residence or a bridging open work permit.

“We are ready to practise in our profession. We are just waiting for our papers,” says the 28-year-old, who worked in the intensive-care unit of the Manila Doctors Hospital, one of the top hospitals in the Philippines, for three years until September 2019, when she was hired as a nanny in Toronto.

“They’re talking about the shortages of nurses in Ontario and Canada. And here we are. The only thing that’s keeping us from our practice is a piece of immigration paper.”

According to Ontario’s regulatory body of nurses, there are currently at least 41 applicants who meet all of its registration requirements but are waiting for the immigration authorization to work in Canada. It’s not sure what the numbers are for other provinces.

Statistics Canada reported that in the first three months of this year, the health-care and social-assistance sector had the largest year-over-year increase in job vacancies compared to other sectors, rising by 27,700 to 98,700 vacancies — an increase of 39 per cent. The positions with the largest vacancy increase were registered nurses and registered psychiatric nurses. Half of those positions had been vacant for 90 days or more, according to Statistics Canada.

Ontario has, so far, been hardest hit. With a ratio of 725 registered nurses per 100,000 people, it ranks as the lowest province in Canada and well below the national average of 811 nurses per 100,000 people, according to 2019 data from the Canadian Institute for Health Information.

Hospitals across the province currently have a vacancy rate of 18 to 22 per cent for nurses, the Ontario Nurses’ Association says.

“Some smaller hospitals closed their emergency departments after four o’clock because they don’t have enough staff,” says Vicki McKenna, head of the association, adding that some operating rooms are running at limited capacity for the same reason..

While complaints from internationally trained nurses have traditionally had to do with the lengthy registration and licensing process with regulators, McKenna said it’s deplorable that those who have met the licensing requirement are being held back due to an immigration backlog.

“We need these nurses, and we can’t afford to have them languish on that list, and we can’t afford to lose them to other provinces. The nursing shortages aren’t in Ontario alone. It’s across this country and it’s an international issue,” she said.

“The U.S. is recruiting hard. Our nurses are leaving, in some cases, to what is seen to be greener pastures there, and we can’t afford to sit and watch. We have to do something.”

Reduced processing capacity due to lockdowns here and abroad, as well as travel restrictions worldwide, have wreaked havoc in the immigration system during the pandemic.

As of July 31, more than 561,700 people were in the queue for permanent residence and 748,381 had a pending temporary residence application as students, workers or visitors, while the backlog for citizenship stood at 376,458 people.

Traditionally, many internationally educated nurses from the Philippines, the Caribbean and Africa arrive and work as foreign caregivers while trying to register and restart their licensing process in Canada once they’re here.

The permanent residence backlogs for foreign caregivers began long before the onset of the pandemic in early 2020. In April, Immigration Minister Marco Mendicino announced a move to prioritize the permanent residence applications of 6,000 caregivers by Dec. 31.

The immigration department said it had processed the applications for a total of 3,253 people under the initiative up to Oct. 17, but it’s not known how many of those were caregivers because the number included their family members. Officials were unable to say how much the caregiver backlogs have been reduced since the announcement.

“Immigration, Refugees and Citizenship Canada has prioritized applications from workers in essential occupations in agriculture and health care, where labour is most needed to protect the health of Canadians and ensure a sufficient food supply,” said department spokesperson Rémi Larivière.

“Applicants who intended to work in agriculture or health care but who applied for an open work permit and didn’t have a valid job offer in advance would not be triaged for priority processing.”

Deauna said she was thrilled with the government announcement, but feels those with pending nursing licences should be fast-tracked if Canadian officials are serious about addressing the shortages of nurses in the country in the wake of the pandemic.

She applied for permanent residence and the bridging open work permit in August 2020 but only received an acknowledgment of receipt this past June. Her caregiver work permit has expired since June.

The Ontario licensing process requires of applicants practical nursing experience within the three years before a certificate of registration is issued.

Deauna fears she may have to go back to the Philippines to get back to practice and restart the licensing process if her immigration and nursing certificate don’t come through before June.

“I can’t afford more delay in my permanent residence or open work permit,” she noted.

Leslie Apurada arrived in 2018 under the home support worker program to look after an elderly man with dementia in Montreal and initiated her licensing process with the Ontario College of Nurses a year later.

The former Filipino registered nurse with a psychogeriatric background underwent Canada’s national nursing assessment, registered for prep courses and sat for — and passed — a couple of required nursing exams, all while working full time to look after her client.

Even though her employer was supportive and tried to spare her from overtime work while she was studying for exams and attending courses, Apurada said she was mentally and physically exhausted jumping through all the hoops to get past the final qualifying test in June. She’s since been waiting for her immigration authorization to work.

“During the height of the pandemic … Canada’s prime minister said we’re all in this together. But we, caregivers, feel we’re always pushed to the sideline. No one really answers to us why the backlog for the caregiver programs has been so extensive,” said the 31-year-old, who is now enrolled in an online course about nephrology at Humber College.

“It’s disheartening to see how strained the Canadian health system is while all along we are here. We’ve passed all the exams and we could’ve helped.”

Karla Ducusin, another former RN from the Philippines, came to Canada in late 2018 by way of Israel to look after an elderly couple with medical needs in Markham. She’s responsible for preparing them meals, administering their medications, escorting them to doctor’s appointments and helping with household chores.

The permanent residence application that she filed last October costs $1,050 and each time she extends her caregiver work permit, it’s another $155.

Given she’s now in Canada on the so-called implied status — in transition with a pending permanent residence application in the system, Ducusin said she has lost her OHIP, which requires a temporary foreign worker to have a valid work permit to be eligible. Her caregiver work permit expired last November.

“I want to be able to help my family more financially. My father is sick and my two younger brothers are not working. I could make a lot more money and pay more taxes as a nurse than as a caregiver,” said the 32-year-old, whose file will be closed by the College of Nurses of Ontario if there’s no update for two years.

“This is putting a heavy toll on our mental health. You wake up every day and there’s still no movement in your immigration application. It’s just so frustrating.”

Source: Canada has a big-time nursing shortage. So why can’t these two fully certified nurses get the OK to practise?

Helping immigrant nurses a ‘win-win’ for Canada: Study

An example where more effective foreign credential recognition and related bridging programs can help:

As baby boomers age, Canada faces a looming health-care crunch that will be exacerbated by a projected shortage of tens of thousands of nurses.

That makes it more important than ever for Canada to help foreign-trained nurses qualify to practice here, according to a Conference Board of Canada study.

Each dollar invested by Ottawa and provincial governments in helping registered nurses acquire Canadian licences generates $9 in future income tax revenue — a nine-fold return, according to the study — not to mention their contributions to the care of the country’s rapidly aging population.

With seniors outnumbering children for the first time ever, according to new Statistics Canada figures, and a projected shortage of 60,000 nurses by 2022, investing in bridging programs makes immense sense, experts say.

“This is a win-win for Canada and the internationally educated nurses (IEN),” said Michael Bloom, the conference board’s vice-president in charge of industry and business strategy. “The concept of investing in career bridging programs is good and sound. It yields returns.”

According to the study, more than half of immigrants with health professional backgrounds have trouble getting their foreign credentials recognized in Canada, compared to just 40 per cent in other regulated professions.

In 2011, only 54 per cent of foreign-born and educated nurses had a job that matched their education in Ontario, with unemployment rates among foreign-trained registered nurses at 6 per cent and 8.3 per cent among registered practical nurses.

Source: Helping immigrant nurses a ‘win-win’ for Canada: Study | Toronto Star

Immigrant nurses face new hurdles with Ontario’s licensing changes

Another example of foreign credential recognition challenges. Given that the certification  is test scenario-based, expect that the main challenge is not technical but contextual and related to how one interacts with patients and colleagues.

But the lack of appropriate training and feedback should be addressed:

The report, released this summer, found that “some internationally educated applicants do not receive adequate explanation about their shortcomings on the OSCE.” And since there are no appeals or repeat tests allowed, “it leaves applicants with no option but to proceed to bridging education if they wish to continue with their RN application,” the report says.

“It is unclear why, regardless of the number of gaps identified in the OSCE, applicants who want to proceed with their RN application must take an entire bridging program. There is no sound justification for the ‘one size fits all’ approach.”

The college said it brought in the OSCE test for foreign RN applicants because it is an objective tool to evaluate competencies.“

It is not an ‘exam’ in the usual sense of the world. It is a holistic assessment of the applicant’s knowledge and experience. . . . They come out of it with a better understanding of which missing competencies they need to address,” said Clarke.

“It’s like getting a second opinion about how well an applicant’s education and experience match the competencies required of a nurse in Ontario.”

Immigrant nurses face new hurdles with Ontario’s licensing changes | Toronto Star.