How does the international migration of health professionals affect gender equity in the health workforce?
The International Organization on Migration recently launched the World Migration Report 2020 which found that the number of international migrants, which is currently estimated to be 272 million, is already higher than anticipated for 2050[i]. This rise in mobility patterns is also visible in the health sector and the implication of health worker migration on health systems is well documented. However, we know less about how migration affects health workers themselves, and how it affects women and men differently.
The intersection of health workforce migration and gender
The feminization of migration can be seen in the growing numbers of female migrants and the increasing autonomy that female migrants exercise in migrating on their own for employment and educational opportunities. In health labour migration, female nurses comprise the largest migrant group[ii] and globally, the health workforce is 70% female[iii]. Healthcare is a highly gendered profession and health labour migration is no different, yet gender equity has struggled to gain traction in international policy and global guidelines on health workforce migration. For example, the WHO Global Code of Practice on the International Recruitment of Health Personnel does not mention gender-sensitive labour migration policy Moreover bilateral agreements and memorandums of understanding on health workforce recruitment overlook gender considerations entirely. As the IOM’s 2020 Report points out,
“the feminization of migration, however, has not been accompanied by more gender-targeted policies for migrant inclusion, which would reflect the particular obstacles faced by female migrants.”
Women make up 70% of the health workforce, but hold only 25% of leadership positions
This brings me to my current research into gender equity in health workforce migration, which I have been conducting for the past 6 months as a graduate student at the University of Washington. I sought to understand if the labour migration process had an effect on four domains of gender inequity in the health workforce; the leadership gap, occupational segregation, the gender pay gap (GPG), and decent working conditions free from harassment, discrimination, and bias. These four domains are detailed in the WHO and Women in Global Health 2019 report, “Delivered by Women, Led by Men,” which provides a thorough gender analysis of the health workforce[iv]. To quickly review the findings of that report:
The leadership gap is best demonstrated by the astounding fact that although women make up 70% of the health workforce, they hold only 25% of leadership positions.
Occupational segregation in the health sector confines women to lower status, lower paid jobs such as community health workers, nursing assistants and nurses or midwives, whereas men tend to hold higher status and higher paid jobs such as physicians, surgeons, and other specialties.
The [unadjusted] GPG in the health sector is higher than for other sectors, with women earning 26% less than their male counterparts on average.
Female health workers experience workplace discrimination, bias, and harassment at much higher rates than their male counterparts.
How does health labour migration affect gender equity in the health workforce?
Through an extensive literature review and in-depth interviews with key informants, the initial findings of my research show that deskilling – i.e. when a health worker practices below their skill level - is common among female migrant health workers and may negatively affect the leadership gap and gender pay gap[v] [vi]. Female migrant health professionals may be more likely to work below their qualification level and receive less pay in exchange for access to quality social services, like placement in a town with a good school system. This would mean that female migrant health workers are not progressing in their careers or earning to their potential, at least during their time abroad but potentially upon their return home as well.
Our analysis also suggests that health labour migration may slightly reduce occupational segregation in nursing by bringing more men into the profession as a pathway for migration. Several key informants we interviewed confirmed that men, in India and the Philippines in particular, occasionally train as nurses with the intention of immigrating for work. Additionally, bottlenecks exist for many physicians migrating into high-income countries, whereas nursing is a relatively efficient and accessible migration pathway. Evidence is still limited and mostly anecdotal, but our preliminary findings are intriguing.
Finally, there appears to be a negative effect on decent working conditions; female migrant health professionals often migrate with an expectation of better working conditions in their destination country - but in reality, experience higher levels of discrimination, bias, and harassment due to their migrant status. Female migrant health workers often face double or triple discrimination based on their gender, ethnicity, and non-citizen status[vii] [viii]. One health worker in the United States described making the difficult to decision to wear her hijab at work despite warnings from her peers that it intensifies harassment and abuse from both patients and coworkers.
Taking a gender-transformative approach to health labour migration policy
According to the WHO, gender-transformative approaches “seek to re-define women’s and men’s gender roles and relations to promote gender equality and achieve positive development outcomes by transforming unequal gender relations in order to promote shared power, control of resources, decision-making, and support for women’s empowerment.”[ix] Gender-transformative policies address the root causes of gender inequities in the health workforce but there is currently no evidence of this approach in health labour migration policy. The first step in mainstreaming gender into migration policy is gender-awareness: policy makers and key stakeholders need to know what challenges female migrants face. This is followed by a thorough gender analysis of health labour migration and ultimately results in gender-transformative action[x].
Both the health workforce and labour migration are highly gendered topics and gender plays a central role in the migration decisions of health workers and their experiences working abroad. Health labour migration policies require a gender-responsive approach to prevent the migration process from contributing to gender-based inequities in the health workforce, and instead should work to transform the role of women in the health workforce.
I would like to thank Corinne Hinlopen for her contributions to this research and Wemos for their support. This research will result in a manuscript that will be publicly available in mid-2020.
Katie Fox shared initial insights from her research in a webinar for the HW4All Coalition on 5 February see on the right and on our Resources-Webinars tab.
[i] World Migration Report 2020.
[ii] Bourgeault I. Gendered Dimensions of Health Worker Migration: Source Country Perspectives [Presentation]. Fourth Global Forum on Human Resources for Health; 2017.
[iii] Delivered by women, led by men: A gender and equity analysis of the global health and social workforce. Women in Global Health. Geneva: World Health Organization; 2019 (Human Resources for Health Observer Series No. 24).
[iv] Ibid, 2019.
[v] Walton-Roberts M, Runnels V, Rajan SI, Sood A, et al. Cases, consequences, and policy responses to the migration of health workers: key findings from India. Human Resources for Health. 2017; 15:28.
[vi] Lim LL. Gender sensitivity in labour migration-related agreements and MOUs. Geneva: International Labour Organization; 2016.
[vii] Walton-Roberts, et al., 2017.
[viii] Lim, 2016.
[ix] World Health Organization, Seventieth World Health Assembly. (15 May 2017). Human Resources for Health and Implementation of the outcomes of the United Nations’ High-Commission on Health Employment and Economic Growth. WHA70/18.
[x] Gender Mainstreaming for Health Managers: A practical approach/Facilitator’s Guide. Geneva: World Health Organization; 2011.
5 February 2020 - HW4All Coalition Webinar on the effects of health worker migration on gender equity in the health workforce.
Speaker: Katie Fox - Master Public Health candidate, University of Washington