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New Cannibal Markets

Jean-Daniel Rainhorn
Samira El Boudamoussi

Part 3. Brain Theft

Selective Immigration: Nurse Importation by Developed Countries

Barbara L. Brush

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1For over six decades, health-care institutions in the United States (US), particularly hospitals in large urban communities, have recruited internationally educated nurses to fill staff nurse vacancies. In more recent years, this practice has intensified in both scope and magnitude in the US and around the world. Nurses’ international mobility, once a oneway exchange between a handful of developed nations and developing countries, has become a more complicated and circuitous stream, with global health-workers moving in new directions and creating new patterns (Kingma 2006). Greater competition for nurse migrants among a broader array of recruiting countries has created a market demand that translates into big business (Brush, Sochalski, and Berger 2004), and with it, more change, more competition, and more consequences.

2In this paper, I examine current trends in global nurse migration, highlighting its effect on nurse workforce planning and development efforts in the US as well as select donor and recipient countries. As will be shown, the shortage of nurses is affecting every nation; many countries both send and receive nurses, while others are becoming increasingly reliant on internationally educated nurses or are experiencing nurse shortages of critical proportions themselves. There is increasing evidence, moreover, that measures to resolve local and national nurse shortages are interfering with international nurse workforce goals, including those set forth by the World Health Organization (WHO), the International Council of Nurses (ICN), and other international bodies. In many countries that provide nurses for export, demand for migrant nurses is exceeding their available supply and threatening their own population’s health. Other nations, meanwhile, have gained a foothold in the lucrative nurse migration enterprise and continue to import nurses to satisfy their staffing needs.

Changing US Nurse-Importation Patterns

3The US has long recruited abroad to fill staff nurse vacancies, although the proportion of international to domestic nurses has been low. Findings from the 2008 National Sample Survey of Registered Nurses (NSSRN), for example, estimated that only 3.5% (or about 100,000) of all registered nurses (RNs) practicing in the US received their basic nursing education in another country (HRSA 2010). This number rose slightly to 5.4% in 2013 (Chen, Auerbach, Muench, Curry, and Bradley 2013) with nurses from the Philippines, Canada, India, and the United Kingdom (UK) leading in numbers. As has been true for decades, internationally educated nurses entering the US are also located unevenly across the nation; in 2008, nearly half worked in urban communities in three US states alone: 26% in California; 12% in New York; and 10% in Texas (HRSA 2010).

4Newer trends, however, show that many hospitals across the US are importing nurses to meet their staffing needs, some for the first time. A 2007 analysis of international nurse trends showed that foreigntrained nurses represented 15.2% of new entrants to the US RN labor force in 2000 (Polsky, Ross, Brush, and Sochalski 2007) and appeared to be rising. Rural community hospitals, where nursing deficits are reaching crisis proportions, are demonstrating a sharp rise in foreign nurse use, as are long-term care (LTC) facilities and home-care agencies across the nation. Today, 28% of all internationally educated RNs and 74% of internationally educated licensed practical nurses (LPNs) work outside hospital settings, percentages that far exceed the proportion of US nurses in those settings (Pittman, Folsom, and Bass 2010).

5Recruitment agencies in the US have capitalized on the nation’s continued reliance on internationally educated nurses, although, because there is no central registry of recruiters, one cannot accurately estimate the size of the industry or the number of institutions who utilize their services. Of the 273 active recruitment agencies that were located by Pittman, Folsom and Bass in 2010, however, slightly more than half use a “placement” business model that charges health-care organizations a flat fee per recruited nurse (typically between $5,000 to $15,000). Others use a more lucrative “staffing” business model that essentially “leases” nurses to health-care organizations for short terms and then renegotiates new, and usually higher, fee contracts for longer periods. Of the 273 firms cited, 147 recruited broadly across the world but focused mainly on higher-resource countries or countries such as the Philippines, India, and China, which support nurse emigration. More concerning were that 74 (27%) companies admitted to active recruitment in 11 of the 57 countries identified by the World Health Organization (2006) as experiencing critical shortages of health-workers, 36 of which are located in Africa.

New Markets, New Competition

  • 1 Commission on Graduates of Foreign Nursing Schools (CGFNS) data compiled with assistance from Cath (...)

6Along with the US, Ireland, New Zealand, Australia, the UK, Canada, and Saudi Arabia are the world’s heaviest nurse recruiters (England and Henry 2013; Humphries, Brugha, and McGee 2012). The Philippines, long the world’s leading nurse exporter, is now competing with other countries that are increasingly preparing nurses for the international marketplace. Over the past decade, for example, India significantly stepped up nurse exportation such that in 2004, it surpassed the Philippines in nurses admitted to the UK’s Nurse Register for the first time (Nursing & Midwifery Council 2005). Indian nurses sitting for the US licensure examination rose twelve fold between 1996 and 2006 (from 1,981 to 24,242) (CGFNS 2005).1 Today, while nurses from the Philippines still predominate in the US market, Indian, Caribbean, and sub-Saharan African nurses have inched up in numbers. South Korean nurses, currently the second highest number passing RN licensure examinations in the US (HRSA 2010), and Chinese nurses, discussed as “possible” or “potential” nurse migrants less than a decade ago, are now migrating abroad in such large numbers that there are concerns about the effect of the nurse brain drain on Taiwan’s public health (Fang 2007).

7The shift in countries sending nurses abroad also reflects a departure from nurse recruitment that previously focused primarily on countries with colonial linkages, i.e., the US and the Philippines and the UK and South Africa and Australia, as well as that traditional suppliers of nurses are experiencing their own nurse shortfall. As a consequence, recruiting countries that relied on familiar labor pipelines are looking elsewhere, and donor nations are themselves recruiting. Improved salaries remain the driving force for migration although nurses cite other motivations for accepting overseas positions, such as unsafe work conditions and limited career prospects at home (Kingma 2006).

Consequences of Change: India and the Philippines as Case Studies

8To underscore today’s shifting international nurse market and its cannibalistic tendency to feed richer nations with the resources of low-and middle-income countries, let us shift our lens to a closer examination of the Philippines—as the world’s largest nurse exporter—and India, a rising competitor in the nurse exportation business.

9The Philippines provides an important example of how international nurses’ mobility affects local balances of health workforce and public health needs. The Philippines case study also highlights the commodification of human resources as a key national economic strategy. For example, over the past five years, in an effort to maintain its prominence in the global nurse marketplace, the Philippines has implemented new tactics for easing nurse exportation and ensuring employment of its migrating nurses, such as the creation of testing sites in Manila to facilitate nurses’ preparation for practice in the United States. Efforts to manage migration to neighboring, as well as new, countries have also been instituted in the form of bilateral economic agreements. The 2006 Japanese-Philippines Economic Partnership Agreement (JPEPA), which promoted the flow of goods, services, and capital between Japan and the Philippines, also contained unique provisions allowing Filipino nurses to work in Japan. The idea was that the inflow of several thousand Filipino nurses would satisfy the need for more health-care workers for Japan’s aging population and, in return, advance economic development between the two nations (JPEPA 2006). After five years, however, few nurses availed themselves of the opportunity, likely because numerous other and more lucrative offers awaited them. Not to be dissuaded, however, the Philippines and Germany entered into a bilateral agreement in December 2013; with four Filipino nurses entering the German labor market for the first time. Pre-screened nurse applicants are required to complete German language training and pass the German nurse licensure examination. The four new applicants are currently working as nurse assistants until completion of all requirements, and another group was expected to arrive in January 2014.

10In recent years, the Philippines has struggled to determine how best to lose nurses, gain remittances, and maintain the public’s health. Filipino nurses have been sought after worldwide, yet find it difficult to find fulfilling and well-paying positions at home (Dimaya, McEwen, Curry, and Bradley 2012). Inadequate wages and reports of high patientto-nurse ratios have led most of the top graduates of the Philippines’ nursing programs, as well as the country’s most seasoned nurses, to migrate, creating anxiety that care rendered to the local populace, especially those in rural communities, is in the hands of less experienced, less qualified personnel. A further complication is the country’s perennially low national pass rate on the Philippines’ nurse licensure examination, thought to be related to the unfettered growth in nursing programs, whose large student numbers outpace available nurse faculty supply and whose educational standards are questionable. That only 16,908 (34%) of 49,000 exam takers passed in 2012 (Republic of the Philippines Professional Commission 2012) suggests that the problem continues, and, if most of that third then migrate, a considerably thin pool of licensed nurses will remain at home. Thus, while Filipino nurses working abroad remit wages that may improve the Philippines’ economic health, there is a potential cost to the nation’s public health.

11Underlying the surge in Indian nurse emigration is the creation of new businesses focusing on global nurse staffing. The largest, the Apollo Institute of Health Sciences, represents a network of Indian hospitals that developed a for-profit Global Nurse Program to prepare hundreds of nurses specifically for export to the US, the UK, and Australia (Evans 2006). Max India’s three-year international nursing program also prepares nurses for the global market, while World Health Resources and Athma Healthcare partner independently with Arizona-based United Staff Solutions to bring Indian nurses to their hospitals. The latter program, essentially a private bilateral agreement between health-care entities, mandates that its nurses participate in a 30-day orientation to American culture along with speech therapy for accent reduction (Evans 2006).

12A 2006 multisite survey of 448 hospital-based nurses practicing across India revealed that 63% intended to emigrate, citing as motivating factors dissatisfaction with work conditions and the low esteem placed on nurse’s work (Thomas 2006). Better income prospects and professional development opportunities have also been cited as common reasons for accepting overseas positions. In a one-year period between 2004 and 2005, 189 nurses resigned from Holy Family Hospital in New Delhi to take nursing positions in Saudi Arabia, the UK, Ireland, and the US (David 2005). While the hospital rapidly replaced them because of New Delhi’s urban appeal and the hospital’s ability to attract new nurses readying for export, the depletion of the country’s more qualified nurses is concerning (Hawkes, Kolenko, Shockness, and Diwaker 2009). There is already evidence of disparate childhood immunization rates across the country along with rising rates of non-communicable disease (e. g., heart disease) in rural communities, pointing to the need for policies to address adequate health system support—including health-worker planning—to avoid a crisis in health-care.

“Managing” Global Nurse-Workforce Imbalance

13As the international trade in nurses grows virtually unabated, international organizations have designed initiatives and created policies to address nurse workforce development and retention. In 2001, the International Council of Nurses published its position statement governing nurse mobility and the ethical recruitment of nurses internationally (ICN 2001). In 2006, WHO issued “Working Together for Health,” calling for collective strategies to improve nurse education and employment to promote retention and lessen national nurse shortages. The Organization for Security and Co-operation in Europe and the International Organization for Migration (2006) urge countries to practice managed migration to meet the needs and preserve the rights of key players involved in the global nurse market, while other stakeholders support labor migration policies that maintain healthy systems of care for local populations.

14These efforts, aimed largely at national policymakers and directors of care delivery and provider education systems, are hardly new. Nearly 30 years ago, at the 1986 Acapulco Council for International Organizations of Medical Sciences (CIOMS) meeting, WHO Director Dr. H. Mahler argued that adequate health professions planning, production, and management depended on the collaboration between educators, employers, policymakers, and society and that, without such collaboration, national health-for-all strategies would be implausible (Bańkowski and Fülöp 1987). Today, many of the global health-manpower problems discussed in Acapulco persist or have escalated in three key areas: maldistribution (especially between rural and urban communities), inequalities in health-care access and provider-to-patient ratios, and inadequate resource allocation for training and remuneration.

15Recruiting countries too are facing internal pressures while attempting to balance nurse demand with an international supply of nurses. In August 2006, the UK limited its nurse recruitment to European Union (EU) countries, granting work permits only to nurses from non-EU countries if National Health Services’ institutions demonstrated that jobs could not be filled by UK or EU applicants (Depasupil 2006). The American Nurses’ Association, vocal about escalating nurse migration and its opposition to US immigration policies that lift visa caps for importing nurses, call for “homegrown solutions” rather than reliance on foreign nurses to fill nurse shortfall (Doheny 2006, 39). If institutions do hire from abroad, however, the US’s Voluntary Code of Ethical Conduct for the Recruitment of Foreign Nurses lays out clear guidelines for ethical hiring and employment practices (Cho, Masselink, Jones, and Mark 2011).


16Despite ongoing debate about how best to manage nurses’ international mobility, nurse migration remains relatively unchecked, uncoordinated, and individualized, such that some countries suffer from its effects while others benefit. This is not surprising given the varied nature of nurse migration between countries, inconsistent approaches to nurse-migration management, and the proliferation of independent for-profit recruitment agencies.

17It has been previously argued that strategies to manage nurse migration can only achieve success if all stakeholders are involved (Schmid 2004). Others contend that policies which remain largely directed at the symptoms of the problem rather than the cause create further workforce inequities. Still others suggest that more data is needed to develop and finance an international framework that creates equitable migration pathways. In any case, to be effective, nurse-migration policy and guidelines for ethical recruitment must consider the specific needs and motivations of various stakeholders as well as ways to more carefully regulate the private business interests of recruiters and others actively recruiting nurses.

18At the most basic level, global policies to manage nurse migration fail because neither developed or developing countries are creating sustainable professional nurse workforces that meet their own needs. Bilateral agreements between some countries and efforts by others to manage international nurse recruitment are a beginning but fail to address fundamental deficiencies in the systems that created the need for such strategies in the first place. Whether losing nurses through migration or attrition, countries lower their capacity to provide adequate quality health-care to their constituents when they underinvest in nursing. National policies must first consider how to maximize human resources to build nursing capacity without looking outward for solutions. This includes improving nurses’ work conditions, educational capacity, salaries, professional growth and development, and broader roles in public health policy and practice. When nurses choose to migrate, they should be uniformly regulated through governments rather than through independent agencies so that their paths to employment are fair, visible, and measurable. Unless these efforts are coordinated between nations and consideration is given to who will implement, regulate, and measure their effectiveness, they are bound to fail again and again.



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1 Commission on Graduates of Foreign Nursing Schools (CGFNS) data compiled with assistance from Catherine R. Davis PhD, Director of Global Research and Test Administration, CGFNS, Philadelphia, Pennsylvania.


The Lake Professor of Nursing in Population Health and an associate professor at the University of Michigan. Her research focuses on international nurse migration and nurses’ work around the globe, including controversial aspects related to racial segregation and immigration policy, for which she is regularly consulted. She completed her baccalaureate degree from the University of Massachusetts and her master and doctoral degrees from the University of Pennsylvania.

© Éditions de la Maison des sciences de l’homme, 2015

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