Who migrating health workers are, why they migrate and the consequences of their migration are important details for consideration in health workforce and migration policy design and planning. Although there has been a visible growth in knowledge that gender roles affect health workers’ reasons for migrating and their migration experiences (George 2007; Piper 2005; Spitzer, 2016a, 2016b; Walton Roberts 2019; Yeoh, 2014), an acknowledgement that gender is an important consideration or factor, health worker migration-related policies and regulations show little in the way of systematic consideration or sensitivity to gender. Although gender differences are present, their invisibility and lack of attention to them can lead to social inequality, and labour market and health inequities.
In some ways, this trend of the issue being hidden but all the while in plain sight is not so surprising: classical theories of migration of the 1960s and 1970s were focused on the assumption and stereotypes that migration decisions were men’s and migration experiences were universally male. Men’s experiences were considered the standard: women and families who accompanied them were assumed to be passive and invisible (Piper 2005). More recently, there is evidence of the feminisation of migration (Camlin, et al, 2014; Ryan, 2002) where women constitute 44.3 percent of the estimated 244 million international migrants world-wide (McAuliffe and Ruhs, 2018). Although some countries have restricted women’s migration as a result of patriarchal ideologies and policy (Kingma, 2006), women migrants are increasingly moving independently of partners or families (Kofman, 2004; Timur, 2000).
Migration is thus becoming better understood as highly gendered as gender impacts men’s and women’s roles and experiences of migration differently (Spitzer, 2020; Spitzer and Piper, 2014; Walton-Roberts 2019). Although migration studies have generally become more gender analytic in nature (Donato et al, 2006; Spitzer, 2016a, 2016b), the literature however remains modest on certain issues pertaining to gender and migration policy.
The feminization of migration is particularly striking for health workers with female nurses, for example, globally forming the dominant health worker migrant group (Brush and Sochalski, 2007; Walton Roberts 2015). Indeed, women migrants are over-represented globally in health and care sectors in which care-work has typically been undervalued (Folbre, 2012). Moreover, nurses and other feminized health workers are often disproportionately impacted by health government austerity and cutback to healthcare investment (Shannon et al 2019). Yet, while the migration of women as skilled health workers contributes significantly to global labour markets and migration patterns, the “gendered effects of migrant health workers on their personal and professional lives within the context of specific health occupations and specific recipient and source health systems” (George 2007; p. 37) remains under explored.
Undertaking a gender-based analysis starting with sex disaggregation of data (female versus male) of migrant health workers can help in the interpretation of differences in women’s and men’s migration motivations and experiences. A more complex and nuanced view of gender does much more when it takes into consideration the social roles, relationships, behaviours, relative power and other traits that societies generally ascribe to women, men, and people of diverse gender identities (Hankivsky 2013; Schiebinger et al. 2014). Further, migration decisions are not only influenced by gender at the individual and household level, but also at the institutional and policy level (Bourgeault et al., 2016). The gendered nature of the division of labour in health care (Kuhlmann et al, 2012; Jones et al., 2009), for example, and how that is uniquely configured in both source or sending and recipient countries also has implications for understanding better the gendered nature of health worker migration and its impacts.
In the country-based empirical analyses we undertook of some of the key global health worker source or sending countries (Labonté et al., 2015; Palaganas et al., 2015; Tomblin-Murphy et al., 2015; Walton Roberts et al., 2015), we found many suggestions that gender played an important yet unnoticed role for potential migrants and migrants, the workplaces and families left behind, and social and health policies. In this paper, we explicitly analyse these gendered aspects of health worker migration from the three key data sources – country-based documentation, health worker surveys, and interviews with key stakeholders carried out for the study. We highlight the gendered aspects of health worker migration from both the literature and the findings from our country case studies of health worker migration. Theoretically, this paper’s analysis builds on the extant literature on gender-based analysis and employs the typical (although non-gendered) push/pull theories of international labour market mobility as an organizing framework. Second, we draw upon insights of the gendered impact of health worker migration on formal and informal sectors in source countries, with a particular focus on immigration and emigration policies.
Gender And Health Worker Migration
Gendering push-pull factors influencing health workers decision to migration
There is a tendency in the health worker migration literature to focus on individual level factors emphasizing how certain ‘push’ and ‘pull’ factors influence personal decisions to migrate by individuals and families (Bourgeault et al., 2016). Factors pushing health workers to migrate include poor wages, limited opportunities for professional development, heavy workloads, economic instability, poorly funded health care systems, the burdens and risks of HIV/AIDS and safety concerns (Labonte, Packer, and Klassen, 2006; PAHO, 2001; Robinson and Carey, 2000; WHO, 2006). Pull factors include better and more comfortable living and working conditions, higher wages and greater opportunities for advancement and promotion (Aiken et al., 2004; Buchan, 2002; WHO, 2006). Health workers such as doctors and nurses from source countries are considered to be highly skilled and experienced personnel (Stilwell et al., 2004). Further, migration is not necessarily a young person’s game: One older study reported that more than 40% of migrant nurses from South Africa, India, Pakistan and Mauritius were aged 40 or older (Buchan et al., 2006).
The push and pull factors approach to migration is a popular approach and useful for a descriptive means of organizing and listing factors at the individual level. However, it provides little distinction of their relative importance, nor analytic attention to root causes at a more structural level, including the influence of gender and its association with the broader political economy (Bourgeault et al., 2016, Kingma 2006; Walton-Roberts, 2015a). It can also be critiqued for neglecting the historical (and gendered) nature of colonial and post-colonial relations, and other social divisions in its analysis of the migration dynamic (Hagopian et al., 2005). Gender is intricately implicated in the migration decision of health workers through the gendered discrimination and inequality experienced at home and abroad, and perpetuated by traditional societal attitudes towards women and the care work they undertake (e.g., Adhikari, 2013; Byron, 1998; Ryan, 2008). Factors typically characterized as push, such as poor working conditions and low earnings, are often indicators of women migrants’ labour market marginality (Piper, 2005). Moreover, the global demand for care-workers coupled with the expectation that women should earn for their families’ well-being—discourse that is underscored by public declarations that migrant workers sustain the national family—help propel out-migration (Spitzer, 2016a).
The Public Services International’s participatory research on migration and women health care workers conducted in a number of countries demonstrated that women health workers were besieged in several ways. Foremost, structural health sector reforms had negative effects on women health care workers, who are often subject to low and inequitable wages, and violence in the workplace, while they need to work to support their families, and hold full responsibility of care for them (Pillinger, 2011, 2012). All these factors can converge to cause women to migrate sometimes leaving their families behind, and/or leave work in the health sector altogether.
The gendered nature of transnational social networks, which increase female health workers’ awareness of migration opportunities, also have a particular influence on their decisions (Nair, 2012; Le Espiritu, 2005; Ryan, 2008; Hagan, 1998). Ryan’s (2008) work on Irish nurses who migrated to Britain in the postwar period reveals, for instance, that most of them were encouraged to migrate by female relatives, especially sisters, aunts and cousins. Adhikari (2013) similarly illustrates how female nurses in Nepal are encouraged to migrate by women in their families; their migration is seen as a collective family investment, the key return on their investment being remittances that are sent back. Scholars are increasingly recognizing how gender intersects with various push and pull factors to influence migration decisions of health workers.
Emigration policies in source countries
Studies of labour migration have often treated sending states as “unimportant auxiliaries” (Paton, 1994), merely reacting to the demands of the more powerful receiving nation-states which consume their citizens’ labour. This under-theorization of what the sending state does before the migrant leaves, and the impact of sending state policies on the skills composition, geographical reach and scale of international migration, remains an important research gap in the migration field (Lee, 2017), and particularly as it relates to health workers.
Policy changes that have taken place in both source and destination countries are instrumental in precipitating and tempering women’s migration (Bandita, 2015). Although International human rights’ laws affirm that an individual has the right to leave and return to one’s own country (United Nations General Assembly, 1948) Article 13 (2), some countries have placed gender-based limitations on emigration based on law or social norms (e.g. women from Iran are not allowed to emigrate without permission of a husband or male relative if single). As Ferrant et al. (2014) explain, “High levels of discrimination against women reduce their ability to migrate … [and] deprive women of the resources necessary for cross-border migration.” (p. 4).
Examination of states’ emigration and immigration policies, cultural norms that foster international migration in some cases and prevent it in others, and the extent of women’s autonomy in making decisions to emigrate, provides additional evidence that gender is excluded in push/pull considerations in the wider literature. Restrictions or guidelines on women migrating are often quite specific to their gender, whereas restrictions placed on men are most likely to be targeted at the job class/profession. Emigration restrictions on women from Asian countries include: the banning of the recruitment of certain sectors dominated by women e.g. domestic helpers; restrictions on age of female migrants; selective bans on employment depending on destination country; and requirements of educational qualifications before exit permission would be granted. These restrictions are not equally applied to men (Oishi, 2002).
Gendered impacts of health worker migration on source countries
Migration can have positive impacts both formally on healthcare and informally in other sectors. For individual health workers, migration can bring about gains in social and professional status, and these can be accentuated for women. Indian nurses who hold visas to work overseas, and therefore have the potential to migrate, become preferred as potential wives because they can supply their own dowry, earn a wage, and buy a ticket for their future husbands (Percot, 2006; Walton-Roberts, 2012). Families ‘at home’ can also benefit from the significant contribution that remittances make to source country household incomes. Philippines and India for example view health worker migration positively because of the receipt of remittances. When confronted with situations of under- and unemployment, endemic in the gender dominated health care sector, migration offers significant opportunities for health workers to apply their training in an international context (Jones et al., 2009).
Reports of negative impacts of migration, gendered or otherwise, dominate the literature. Health worker shortages resulting from migration can have adverse effects on care delivery, and in turn population health and health equity in source countries (Labonté et al., 2015; Palaganas et al., 2015; Tomblin-Murphy et al., 2015; Walton Roberts et al., 2015). The emigration of healthcare workers can mean that countries lose their investments in public education and training, which are further compounded with later loss of income tax revenue from highly skilled workers (Jones et al., 2009; Hagopian et al., 2004). How gender impacts these shortages is less specific: that nurses are a very large group of health professionals and the majority of nurses are female means that migrating female nurses are lost to the sector, but filling the workload gaps that result from job vacancies and staff shortages, also falls to (predominantly) female nurses. While the levels of violence against women health workers have already been acknowledged as high in many countries (Cooper & Swanson, n.d.; Henderson & Tulloch, 2008; Needham et al., 2008), there is potential for additional harmful consequences. For example, some authors have suggested that as a result of migration, women workers face increased workload with attendant stress and low morale (Jones et al., 2005; Pan American Health Organization (PAHO), 2001).
Migration may improve social status of some women nurses, but it exposes others to deskilling, sexism and racialization in destination countries (Pratt, 2004). Although likely to be migrating for their own economic purposes, female migrant health workers are vulnerable to certain experiences that male counterparts do not experience, including increasing risks to their own health. In addition to such vulnerabilities, according to the International Labour Organization (ILO) and Public Services International (PSI), there is a clear trend of undervaluing women’s work across professions (Lu-Farrer, Yeoh, & Bass, 2020; Pratt, 2004).
Women’s decisions to migrate, particularly if seen for individualistic reasons, are not without criticism. Hull (2010) wrote how female nurses can receive gender specific condemnation from others for abandoning or neglecting family in their pursuit of financial gain. Outside the health sector itself, when female health workers emigrate, the knock-on effects of migration have effects on other women. Women’s gendered roles are typically taken over by other women – older, younger or of lower status, who carry the burden of increased care responsibilities for sick or elderly family members in the context of weakened and under-resourced health care systems (Akintola, 2004; Eckenwiler, 2011; Jones et al., 2009; Makina, 2009; Nelson, 2002). Surrogate parenting for children is often provided by siblings and other female family members (Jones et al. 2009). Citing Nelson (2002), Eckenwiler (2011) maintains that “there is now abundant evidence to suggest that caregiving responsibilities—doled out and taken on the basis of gender norms and the social and institutional policies that exploit them—have profound effects on … family caregivers” (Eckenwiler, 2011, p. 10). The concept of global care chains, coined by Hochschild (2000), and applied to the case of nurses by Yeates (2004, 2009) recognizes the role of female migrants as carers abroad, the care deficit left to be filled by women back home to whom their care responsibilities are transferred.
In summary, the literature of health worker migration has begun to show and acknowledge that gender is an important determinant of migration affecting the decision to migrate, the experiences of migrants, and impacting the formal and informal sectors in source and in destination countries. The exploration of these issues is still relatively limited and remains evident in policies in which gender plays a significant role, for example codes of practice that implicate international health worker migration. (Commonwealth Secretariat, 2003; World Health Organization, 2010). Critiques of the Code have failed to make visible sex and gender-based analyses (Bourgeault et al., 2015; Brugha & Crowe, 2015). Invisible in particular are the perspectives in sending countries and experiences of health workers and the lack of knowledge of gender and gender-based analysis by stakeholder decision-makers. These gaps clearly have implications for migration policy development and health workforce planning.