The nurses' dilemma



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In recent years, international nurse migration has been a trend on the rise and the number of nurses moving from the developing to the developed world has soared. Increased nurse mobility is deeply interlinked to the phenomenon of global nursing shortage, which refers to a situation in which the demand for nursing professionals exceeds the supply. Because of this, in the last couple of decades, countries like Australia, the US and the UK have started to recruit foreign nurses to meet their domestic demand. The main factor explaining this increased need for nurses is the so-called demographic asymmetry, indicating a situation of declining fertility rate coupled with increasing life expectancy, which results into a growing number of elderly people requiring extra health care. In response to this global nurse shortage, many developing countries are sending their nurses abroad, in the attempt to take advantage of the employment opportunities that this situation provides. Migration of skilled workers like nurses certainly brings some advantages (for example in terms of the remittances sent back home), but it can also be very detrimental to the source country if it impairs its ability to deliver vital health services to the local community. In fact, although western countries’ health services have in general benefited from increased nurse mobility, one of the direct effects of international recruitment and migration of

nurses is the exacerbation of shortages in the country of origin, since poor nations with fewest nurses are losing them to wealthy countries with the most nurses.

Nepal is a very good example of source country that might be severely affected by increased mobility of nurses. Like in many other developing countries, nurse education is often seen as a ‘ticket’ out of the country and consequently, the number of schools and colleges offering training has been growing fast in the last few decades. Currently, in Nepal there are 48 campuses offering ANM (Auxiliary Nurse Midwife) programs, 101 campuses running PCL (Proficiency Certificate Level) nursing programs, 21 campuses offering BN (Bachelor of Nursing) programs, 24 colleges running B.Sc. in Nursing, and only 4 campuses running MN (Masters of Nursing) courses. It is estimated that these nursing colleges produce approximately 4,000 nurses annually except ANM, BN and masters courses. According to the Nepal Nursing Council, 16,467 nurses and 17,759 Assistant Nurse Midwives (ANMs) have registered with the council by the end of September 2011. In only a month the number of new registrants was 168 nurses and 325 ANMs, which shows the scale of the nursing human resources produced in the country. Of these, many migrate abroad in search of employment or to get further training. The main reasons encouraging nurses to migrate are better pay and working conditions, greater career opportunities, professional development, personal safety and a better life in general. According to the Nepal Nursing Council records, a total number of 3461 nurses migrated abroad between 2002 and 2011, and their favourite destination countries were UK, Australia and the US. For example, it is estimated that in 2008 Nepal ranked fifth in the hierarchy of source countries of nurses to the UK, where between 800 and 1000 Nepali nurses work. Similar numbers of nurses are believed to have migrated to other countries.

The impact of nurse migration can be said in many folds: on the one hand, migration has direct implications for the individual nurses and their families; on the other hand, migration affects the whole country and its health-care system.

Another type of impact refers to the implications that nurse migration has on the country as a whole. Nurse migration is related to the so-called phenomenon of “brain drain” (the large-scale emigration of skilled people), but it can also be seen as “care drain”, namely the loss of health workers in an already weak health system. In fact, the loss of nurses can weaken a country’s health system especially in rural health, even more when the country is in a desperate need for health-care professionals. Indeed, brain drain of nurses inevitably worsens the already depleted healthcare resources of a poor country like Nepal. As Judith Justice describes that Nepal’s rural health facilities seriously lack nurses and finally these health facilities are run by local peons. There is incredible stress that nurse migration can cause on the country’s health care system. Nurse migration is not the primary responsible for the healthcare human resource shortage, but it certainly contributes to the deterioration of an already difficult situation. Outmigration of nurses might affect even more deeply the delivery of health care in a country like Nepal. In the long run, the loss of nurses will not only worsen the existing shortage, but will also more generally affect the health of the person power present in the country, and eventually slow down the entire process of development. Young Nurses are more motivated to go to work abroad than to serve in rural areas of Nepal due to low pay, insecurity and unsecured future. Thus, nurse migration has an important multiplier effect on the whole country’s wellbeing.

Although the impact of nurse migration can be negative on health, it can also bring about many advantages to the family of the migrants and the entire origin country, in the form of remittances, acquired skills, and employment opportunities gained abroad, especially when Nepal is debating unskilled Nepali women are going to foreign countries for employment. Many have noticed that the phenomenon of ‘brain drain’ should be replaced by one of ‘brain circulation’, according to which the skilled person is only temporarily lost when migrating abroad, and recuperated once it comes back to the country of origin. As stated by Mireille Kingma in her book Nurses on the Move, ‘nurse migration is a multifaceted and intricate social phenomenon. It represents part of the solution for some countries, health systems, or individuals, part of the problem for others’. Determining whether nurse migration is more an opportunity than a problem in the context of Nepal requires particular consideration of all the consequences it brings, both in the personal and countrywide spheres. Nepal needs a special policy and program on Nurse for overseas employment and for the rural health care system.

Gurung is former member of National Planning Commission and Elisa is working with Nepal Institute of Development Studies in Kathmandu

(Sources: The Kathmandu Post)