Personal and home health aides, registered nurses, and medical and nursing assistants are among the fastest growing occupations in the United States. The U.S. Bureau of Labor Statistics projects 1.2 million new personal and home health aide positions – and the need for another 372,000 registered nurses – by 2028. Due to the shortage of qualified healthcare workers, immigrants held 15 percent of all registered nursing positions in the United States in 2016. On April 22, President Trump signed an Executive Order to pause immigration due to COVID-19, but exempted physicians and nurses.
This is not uncommon in developed countries with a growing aging population who are living longer. About eight percent of nurses in Canada are foreign-trained, 15 percent in the UK, 19 percent in Switzerland and 27 percent in New Zealand. The numbers are higher for foreign-trained doctors: 24 percent in Canada, 28 percent in the UK, 27 percent in Switzerland and 42 percent in New Zealand.
Training for Export
India has the world’s highest number of medical schools and is the world’s largest source of immigrant physicians. An estimated 69,000 Indian-trained physicians worked in the United States, UK, Canada and Australia in 2017, according to the OECD. India is second only to the Philippines in training nurses. Nearly 56,000 Indian-trained nurses work in those same four countries, equal to about three percent of total registered nurses in India.
The Philippines has an established international nursing training program and is the largest exporter of nurses globally – accounting for roughly 25 percent of all overseas nurses worldwide. About 85 percent of employed Filipino nurses work in one of more than 50 countries around the world. In the United States, an estimated 20 percent all the registered nurses in California are Filipino. It’s a strong professional cadre. The Philippine Nursing Association of America represents over 145,000 Filipino nurses and has its own theme song.
The “Brain Drain” Concern
Health care professionals migrate for many reasons: continuing education, better pay, the opportunity to send remittances to their families and home nation, the prestige of practicing in another country, and others. Filipino nurses in the United States earn 15 times more than those working in the Philippines. Filipino nurses working abroad remit about $1 billion to the Philippines every year, a substantial portion of total remittances which drives 13 percent of the Philippines’ GDP.
International mobility of health workers is accelerating. The number of migrant doctors and nurses working within OECD countries increased by 60 percent over the last decade, along with significant increases in intraregional mobility and migration of healthcare workers among developing countries.
Public health groups including the World Health Organization (WHO) are concerned that health care immigration reduces the number of professional health workers available to serve their home countries. Developing countries are often especially in need of more personnel. Declaring 2020 the Year of the Nurse and Midwife, WHO says 18 million more health care providers are needed worldwide to achieve universal health coverage by 2030. To address the “brain drain” concern, WHO developed a voluntary Global Code that promotes adequate staffing of national health systems and “ethical international recruitment of health personnel”.
Mobility and “Ethical Recruitment”
In a 2019 joint study, the WHO and World Trade Organization (WTO) examined the relationship between free trade agreements that improve health worker mobility and the recruitment goals of the Code. The study primarily reviewed so-called “Mode 4” commitments that deal with the temporary presence of foreign natural persons supplying trade in health-related services.
Commitments have been made by 139 WTO members to liberalize trade in services. Of those, 69 members have taken at least one commitment relating to the provision of health services, from hospital care to midwife services. The commitments vary widely, enabling education and skills exchanges, investment, mobility for charitable purposes, and the protection of health worker welfare.
As an example, the Indonesia–Japan Economic Partnership Agreement includes development assistance by Japan’s International Cooperation Agency to support nursing education in Indonesia. In 2019, Japan updated its Economic Partnership Agreements with Indonesia, the Philippines and Vietnam to extend the period of time a nursing candidate can stay in Japan to obtain national nursing qualifications and healthcare worker certifications.
The joint WHO-WTO study makes no real conclusion about the compatibility of the Code with greater mobility through trade agreements. It suggests that further analysis such as economic needs tests or labor market tests could help sending and receiving countries understand the impact of healthcare worker service exports on sustainable development.
COVID-19 is Shifting the Global Healthcare Trade Landscape
COVID-19 may be accelerating two key trends in healthcare work, while at the same time reversing (perhaps temporarily) the trend of job growth by inducing layoffs in the industry.
Encompassing remote patient assessment and monitoring as well as health education, the global telemedicine market was projected to grow from $70 billion in 2020 to $266.8 billion by 2026. COVID-19 is accelerating the trend. In March, the U.S. government announced it would temporarily pay clinicians to provide telehealth services for Medicare beneficiaries and would expand the communications platforms that could be used.
Telemedicine has long been encouraged in developing countries, supported by international development agencies and non-government organizations. It can help overcome short-staffing limitations and provide support for local clinicians through overseas physicians who can confirm a diagnosis and collaborate on treatment plans as part of global trade in services.
Robotics are being deployed to decrease COVID-19 risks to frontline healthcare workers. A field hospital in Wuhan, China serving 20,000 patients was staffed by robots that monitored patients’ vital signs through smart bracelets and rings that synced with an AI platform. Other robots served food, drinks and medicine to patients, while other autonomous droids sprayed disinfectant and cleaned the floors. Other countries like South Korea and Lebanon are using robots to measure temperatures, distribute hand sanitizer and perform disinfecting services.
Layoffs and Mobility Restrictions:
COVID-19 is causing governments to retrench in some countries that export healthcare workers,. In March, the Philippine Overseas Employment Administration (POEA) temporarily suspended the deployment of all health care workers “until the national state of emergency is lifted,” freezing the fulfillment of existing contracts with hospitals around the globe. Meanwhile, routine healthcare has been stymied due to ongoing stay-at-home directives, causing massive financial distress to the healthcare industry and significant layoffs.
In all of these ways, COVID-19 may be changing the outlook for cross-border global healthcare services for years to come.
Sarah Smiley is a strategic communications and policy expert with over 20 years in international trade and government affairs, working in the U.S. Government, private sector and international organizations.