Causes, consequences, and policy responses to the migration of health workers: Key findings from India

Abstract

Background
This study sought to better understand the drivers of skilled health professional migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries—Jamaica, India, the Philippines, and South Africa—that have historically been “sources” of health workers migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study. Methods
Data were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists, pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders representing government ministries, professional associations, regional health authorities, health care facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically. ResultsShortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree and nature of such shortages are difficult to determine due to the lack of evidence and health information. The relationship of such shortages to international migration is not clear. Policy responses to health worker migration are also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or desirability of curtailing migration. Conclusions
Consequences of health work migration on the Indian health care system are not easily discernable from other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the international migration of health workers.

Full text

R E S E A R C H Open Access
Causes, consequences, and policy
responses to the migration of health
workers: key findings from India
Margaret Walton-Roberts
1
, Vivien Runnels
2
, S. Irudaya Rajan
3
, Atul Sood
4
, Sreelekha Nair
5
, Philomina Thomas
6
,
Corinne Packer
2
, Adrian MacKenzie
7
, Gail Tomblin Murphy
8
, Ronald Labonté
9
and Ivy Lynn Bourgeault
10*
Abstract
Background: This study sought to better understand the drivers of skilled health professional migration, its consequences,
and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four
countries—Jamaica, India, the Philippines, and South Africa—that have historically been “sources”of health workers
migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study.
Methods: Data were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists,
pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders
representing government ministries, professional associations, regional health authorities, health care facilities, and
educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative
data were analyzed thematically.
Results: Shortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree
and nature of such shortages are difficult to determine due to the lack of evidence and health information. The
relationship of such shortages to international migration is not clear. Policy responses to health worker migration are
also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy
agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or
desirability of curtailing migration.
Conclusions: Consequences of health work migration on the Indian health care system are not easily discernable from
other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in
relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the
international migration of health workers.
Keywords: Health worker migration, Human resources for health, India, Doctors, Nurses, Causes, Consequences,
Policy responses
Background
The global migration of health workers remains an issue
of concern for health provision and development [1, 2].
India is a major source country (exporter) of health
workers, but determining how skilled health worker mi-
gration interacts with the Indian health care system is
challenging to measure, especially in terms of relationships
of causation. Although there are some studies of Indian
health worker migration [3–6], comprehensive data and
analysis on this issue are generally lacking in much of the
current research. We do know that Indian-trained health
workers have played an important role in serving the
needs of overseas health systems since the 1950s [7]. India
remains one of the largest exporters of all health profes-
sionals, it is the world’s largest supplier of physicians [4],
and the emigration of nurses is also significant, with esti-
mates ranging from 20 to 50% of Indian nursing program
graduates intending to seek overseas opportunities [5, 6].
* Correspondence: ivy.bourgeault@uottawa.ca
10
Telfer School of Management, University of Ottawa, 1 Stewart Street,
Ottawa, ON K1N 6N5, Canada
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Walton-Roberts et al. Human Resources for Health (2017) 15:28
DOI 10.1186/s12960-017-0199-y
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Health worker migration (HWM) has thus been assumed
to be associated with shortages and uneven distribution of
health workers. The costs and human capital losses associ-
ated with health worker migration are presumed to be sig-
nificant for India, but, as we outline below, they have not
been fully assessed in terms of overall numerical or policy
significance.
Our four-country study of “source”country for health
professional migration included South Africa [8],
Jamaica [9], India, and the Philippines, countries that
have historically supplied trained health workers for
other countries. We set out to investigate the causes,
consequences, and policy responses emerging from the
international migration of health workers. In this paper,
we investigate these issues in the Indian context, with
specific reference to the states of Kerala and Punjab.
Indian health and health care context
India has a population of 1.26 billion, about 17.5% of the
world’s population [10, 11]. It carries 25% of the global
burden of child deaths and 20% of global maternal deaths
[12] . India is undergoing both a demographic transition
as a result of increased life expectancy and decreased
death and birth rates and an epidemiological transition in
which non-communicable diseases, such as heart disease
and diabetes are rapidly replacing infectious diseases as
the major cause of mortality [13]. Globalization and rapid
economic change have also led to significant social change
including the expansion of the middle class alongside in-
creasing inequality, which together have both enhanced
and changed the demands placed on India’s health system
[14]. International migration and accompanying financial
remittances have increased in parallel with globalization
tendencies, which is a significant policy issue for India
considering it was the largest recipient of migrant remit-
tances in 2013 (70 billion US dollars), and by 2050 is
projected to emerge as one of the world’s largest migrant-
sending countries [15].
Access to health care is heavily influenced by social class
and geographical location, with rural areas being generally
underserved [16]. India’s public health system is meant to
serve the poor majority of India’s population; however, the
private health sector is now playing an increased role in
health service delivery as well as health care training and
education, such that the Indian health care system has
come to be defined by the extensive involvement of the
private sector [17]. The private sector owns 60% of hospi-
tals and 75% of dispensaries and employs 80% of all quali-
fied doctors in India [18].
The public health sector in India is ranked 6th lowest
worldwide in terms of percent of GDP invested in health
(0.9%), but it is among the top 20 countries in terms of
private expenditure on health (including out-of-pocket
expenditures), accounting for 4.2% of GDP [17]. India’s
2015 Draft National Health Policy does not show any
deviation from this path of privatization, rather there are
signs that the private sector will continue to penetrate
public sector health infrastructure including the afore-
mentioned increased role in health care training and
education [19].
In light of both domestic and international demands for
health professionals, the health worker training sector in
India has experienced significant growth, mainly through
private corporate investment [20]. Growth in this sector
has also been driven by an interest in overseas-oriented
employment opportunities [21, 22]. This rapid growth has
raised concerns about the quality of training and the level
of corruption in the regulation of the sector [23]. In this
regard, the Indian health educational sector exhibits the
same tendencies underway in the health care sector, which
has seen annual growth rates of approximately 14% per
annum this decade, and is estimated to hit 21% next dec-
ade, driven mostly by corporate investment. The Indian
government has played a facilitative role in corporate
health care; the “Government has had an active policy in
the last 25 years of building a positive economic climate
for the health care industry”[24], p. 9. The corporate and
global orientation of health care service and training
might incentivize health worker migration at the cost of
slowing National Health Policy reforms. In that regard,
understanding how the two interact remains a key re-
search issue.
As with many developing economies, India faces sev-
eral health workforce challenges, including a lack of
high-quality training, geographic maldistribution of
workers, and loss of workers to overseas destinations
[25]. Indeed, India has been considered to be a “crisis”
country with respect to all health workforce stocks as
identified by the 2006 World Health Report [21, 26, 27]
and, with Jamaica, was one of the two countries in our
four-country study in which the density of physicians,
midwives, and nurses fell below the WHO recom-
mended minimum of 22.8 total midwives, nurses, and
physicians per 10 000 population [28, 29] (see Table 1).
Health worker data produced by India must be inter-
preted with caution. The diversity of India’s health workers
(some of whose practice roles may have been specifically
developed to respond to local need), India’s different sys-
tems of medicine (allopathic, Ayurveda, Yoga, Unani, Sidha,
and homeopathy), its public and private sector health care
and significant regional differences make it difficult to col-
lect data consistently and present a robust data picture with
regard to health workforce and health worker migration
[30, 31]. Data on annual production from educational insti-
tutions is available, but live professional registration data
varies by state (some states do not have professional regula-
tory bodies) and there may be double counting when in-
ternal state-to-state migration occurs [32]. Furthermore,
Walton-Roberts et al. Human Resources for Health (2017) 15:28 Page 2 of 18
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regulatory bodies’data collection and conservation records
are weak in India: when health workers migrate, there are
few if any efforts by the different regulatory bodies to
conserve or maintain continuous records. The reliability of
Indian health worker data is also questionable [31], with
many non-licensed, non-regulated, and non-qualified per-
sons practicing medicine in India. Therefore, the baseline
assumptions with regard to India’s health workforce in
terms of qualified workers and skills, and the full extent of
health worker migration, are unclear.
Methods
This study sought to better understand the drivers of
skilled health professional migration in four source
(sending) countries, its consequences, and the various
strategies countries have employed to mitigate its
negative impacts. The project used the same mixed
method approach for each country, comprising a
scoping review of published literature on health
worker migration, a survey of health workers, and in-
terviews with key stakeholders. In this paper, we re-
port on the India case. All study activities were
facilitated collaboratively by the study’sPrincipalIn-
vestigators at the University of Ottawa and Dalhousie
University in Canada and co-investigators in Canada
(Wilfrid Laurier University) and India (the Centre for
Development Studies in Trivandrum, Kerala, and the
Institute for Development and Communication in
Chandigarh,Punjab).Thestudywasapprovedbythe
University of Ottawa (Ethics Approval Certificate
numbers H07-10-02H and H07-10-02C). In India,
ethics clearance was granted by the Institute of De-
velopment Communication (Punjab) and the Centre
for Development Studies (Kerala).
Site selection
In order to operationalize the research and recognize the
complexity of data collection at the national scale in
India, we focused our empirical research in two states.
In terms of regional differences, Kerala has long been
seen as the main source location for nurse outmigration
[33], and Punjab has seen a substantial increase in train-
ing capacity, especially for nurses, for export [34]. Kerala
and Punjab were chosen due to the states’level of health
care training capacity and their high degree of outward
orientation in terms of international migration; Kerala
and Punjab are in the top three Indian states with the
highest share of total emigrants (outmigrants) residing
in another country [35].
Scoping review
The scoping review of the literature followed the process
developed by Arksey and O’Malley [36], using the
medical subject headings (MeSH) terms “migration,”
“health professionals”/“health workers”/“nurses”/“physi-
cians,”and “India”in a search of PubMed (including
MEDLINE) and Embase databases. We also undertook a
search and analysis of the published and gray literature
and public domain information from a number of stake-
holder websites, including Indian government agencies.
Articles were included if they addressed one or more of
the three research questions, focused on India, and were
published between 2000 and 2012. After inclusion and
exclusion criteria were applied (articles were included if
they addressed the research questions and mentioned
India; articles that related to India but without relevance
to the research questions were excluded) and duplicates
removed, over 160 documents qualified for analysis.
Analysis of the literature was synthesized into a scoping
review report, which highlighted our key findings by the
following themes: context and overview of the Indian
health system; factors influencing migration; implica-
tions of migration, and policy responses. The scoping re-
view was employed to set the guidelines and directions
for the health worker survey and key stakeholder inter-
view schedules.
Table 1 Health worker density for study countries of India, Jamaica, the Philippines, South Africa and for comparison purposes, the
USA (available data). (Source: Global Health Observatory data repository density per 1000) accessed, December 7th 2015 http://
apps.who.int/gho/data/node.main.A1444?lang=en
Country Year Physicians
density
(per 1 000
population)
Nursing and
midwifery personnel
density (per
1 000 population)
Dentistry personnel
density (per 1 000
population)
Pharmaceutical
personnel density
(per 1 000
population)
Laboratory health
workers density
(per 1 000
population)
Other health
workers density
(per 1 000
population)
India 2011 0.743 1.711 0.095 0.529 0.506
Jamaica 2008 0.411 1.09 0.09 0.06 0.21 0.42
Philippines 2011 0.886
South
Africa
2011 0.758 4.72 0.192 0.369 0.153 2.111
United
States of
America
2011 2.452 8.459
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Survey of health workers in Kerala and Punjab
The health worker survey targeted doctors, nurses, mid-
wives, dentists, pharmacists, and other health workers.
Individuals were invited to participate in the study either
through professional association membership or through
their place of work. The survey was in English, and the
questionnaire was broadly replicated across all four of
the project’s study sites. Questions explored respondent’s
training, living, and working experiences as well as their
views regarding the migration of highly trained health
personnel. A total of 1736 Indian health workers com-
pleted the survey using a paper-based format in face-to-
face encounters, 1337 in Kerala, and 399 in Punjab. Out
of this total, 1719 surveys were adequately completed
and could be analyzed (see Fig. 1 for the occupational
sample comparison). The larger sample in Kerala was a
result of our survey being conducted in combination
with a broader migration policy institute survey.
In both states in the country, research teams surveyed
health workers in urban and peri-urban areas. The survey
was completed in south Kerala in Thiruvananthapuram,
central Kerala in Ernakulam, and in Kozhikode in the north.
Interviews were conducted in both public and private places
of work. (A viral infection outbreak in Ernakulam at the
time of data collection and health workers’busy schedules
resulted in fewer completed surveys from this region). Re-
spondents in Punjab came from both rural and urban areas
across the state and public and private health facilities. Sur-
veys were mostly conducted outside (but near) the worksite
at the start or end of shifts. While the survey was written in
English, surveyors used English and vernacular languages
while administering the survey instrument.
In terms of methods of analysis, quantitative data col-
lected from the surveys were analyzed descriptively.
Logistic regression models of respondents’reports of
having taken each of three concrete steps toward migra-
tion—applying for foreign residence, applying for a li-
cense to practice in a foreign country, and applying for a
work permit in a foreign country—were also developed
and run separately for each state. These models mea-
sured the relationships between having taken these steps
and each respondent’s profession, age, sex, and marital
status.
Stakeholder interviews
A total of 74 key stakeholder interviews (KSIs) were car-
ried out in Kerala and Punjab as well as in the Delhi
Capital Region where central government health depart-
ments are located (28 in Kerala, 27 in Punjab, and 19 in
Delhi). In both Kerala and Punjab, KSIs were conducted
in English and the local language (Malayalam in Kerala
and Punjabi in Punjab). Stakeholders held senior level
positions in various health professional associations,
state and national governments, education and training
organizations and associations, councils dealing with ac-
creditation, registration and regulation of health care
professionals, and hospitals (Table 2). The questions fo-
cused on the contextual features of Indian health worker
migration, what consequences could be attributed to
their migration, and what policies were available to ad-
dress the causes and/or consequences of health worker
migration. Dr. Rajan, Dr. Sood, Dr. Nair, Ms. Thomas,
and their research assistants conducted all the stake-
holder interviews in India.
Interviews were transcribed in India and analyzed sys-
tematically and comprehensively using a common
framework developed initially at the University of
Ottawa based on the interview schedule questions.
Stakeholder responses were coded thematically accord-
ingly to the broad causes, consequences, and responses
categories with specific subcodes using Nvivo™software.
Data synthesis was carried out by repeated readings of
the data, refinement of the coding scheme, and the de-
velopment of a comprehensive qualitative and descrip-
tive narrative of the findings for this paper [37]. Because
of the critical nature of some of the questions and ensu-
ing discussions, confidentiality of the respondents’par-
ticipation in the interviews and anonymity was assured
by the researchers. All personal identifiers have been re-
moved in this paper, and the respondents are identified
by a letter and number and general category descriptor.
Results
Causes of migration
Migration intention: who is most likely to migrate?
Evidence from the health worker survey indicates that
the majority of health professionals surveyed were not
intending to migrate in the next 2 years (of those who
Fig. 1 Which one of the following best describes the licensed health
profession category to which you belong? (Source Health Professional
Migration Survey (n= 1719))
Walton-Roberts et al. Human Resources for Health (2017) 15:28 Page 4 of 18
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responded 75% answered “very unlikely,”7.5% “very
likely”), and the majority had not previously applied for
any kind of foreign work permit, residence, or license
(see Fig. 2). With regard to information about migration,
there was also a fairly strong tendency to never seek out
information from recruiters, professional associations,
and personal connects, with recruiters the least likely
source of information consulted (see Figs. 3 and 4). Ap-
proximately 42% of nurses considered migration “a great
deal”or “somewhat”compared to 24% of dentists and
32% of doctors. Of all the professions, nurses were the
least likely to answer “none at all”about their level of
consideration of migration possibilities (27.4% followed
by dieticians and other therapists, dentists, and doctors
at 36.8%) (see Fig. 5).
Results from the regression models for Kerala showed
that, even after controlling for respondents’age and marital
status, their sex and profession were strong predictors of
having taken concrete steps to migrate (Tables 3, 4, and 5).
Compared to nurses, both general practitioner and special-
ist physicians were less likely to report having applied for
foreign residence, a foreign work permit, or a foreign li-
cense to practice. Pharmacists were also less likely than
nurses to have applied for a foreign work permit. Male
health workers were more likely than females to have ap-
plied for foreign residence and to have applied for a foreign
work permit. For respondents from Punjab, the strongest
predictor of having taken each of these concrete steps to-
ward migration was marital status, with respondents who
were single, divorced, separated, or widowed being more
likely to have taken steps toward migrating. The relation-
ships with profession and sex found in Kerala were also
present but were not statistically significant parameters in
the models.
In terms of the sectors with the greater propensity to
provide international migrants, stakeholders indicated
agreement that doctors and nurses in the government
sector were better paid and had more reason to remain
in India. “Doctors or nurses who are serving in govern-
ment rarely prefer to move out as they feel more secure
here than abroad”(A25, Nursing School Representative).
Some commented that the nurses in the public sector
are actually restricted from going overseas: “Only nurses
from the private sector go abroad. [The] government
doesn’t allow anyone working in government sector to
go. Even those who are working in public sector cannot
leave the country without the permission from Ministry
of Health nor can they go to other states”(R39, Hospital
Medical Head). While the imposition of a moratorium
on outmigration from public sector hospitals suggests an
important policy, we did not find widespread evidence
of this approach being used in practice.
International opportunities for pharmacists were seen
as significant, such that even changes in salary and con-
ditions in India would not alter the flow: “Even if you
improve working conditions [the] possibility of reduc-
tion in migration is very [low]. There are lots of oppor-
tunities for pharmacist in foreign countries”(R6, Health
Professional Association Representative). The migration
process for pharmacists, however, was seen by some to
be at the tail end of its recent growth, possibly reflective
of a general expansion of pharmacist training in other
countries: “Impression is that plenty of pharmacists were
migrating, although number is coming down because
the foreign markets are flooded with pharmacists”(P17,
Pharmacy Association Representative). This suggests an
important finding about how fluctuations in inter-
national demand drive interest in migration.
Comments with regard to dentists’emigration sug-
gested increased training of nationals in certain destin-
ation countries were influencing the outmigration of
Indian-trained health workers: “Earlier we had very good
opportunities, because the nationals of those countries
were not educated [in large numbers]. But now their na-
tionals are getting educated and as Indians don’t go for a
Table 2 Number of key stakeholder interviews by sector (Source Health Professional Migration Interviews) (n= 74)
Location Health care
facility
Government Professional association/
council
Recruitment
agency
Training/
education
Non-governmental
organizations
Kerala 4 4 7 3 8 2
Punjab 3 9 6 3 5 1
Delhi 5 2 6 1 5
Total 12 15 19 7 18 3
Fig. 2 Application for foreign work permit/residence/license (Source
Health Professional Migration Survey, n= 1719)
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higher degree like PhD, the opportunities are coming
down”(R14, Academic Director).
Causes of health worker migration
Reasons for Indian health worker migration echo the ma-
jority of research findings identified in the scoping review
that living and working conditions often combine as key
“push”factors [38]. In Kerala, the three work-related fac-
tors identified by the majority of respondents as most im-
portant in their decisions to migrate were all related to
income. These included their income compared to that
earnedbyothersintheirowncountry(chosenby31%of
respondents), their income compared to what is needed to
enjoyagoodqualityoflifeintheircountry(16%),andtheir
income compared to what they would like to earn (15%).
The three living conditions identified by the majority of re-
spondents as most important in their decision to migrate
were the cost of living (29%), the ability to find the job they
wanted (22%), and the safety of their family (9%). The
working conditions that were identified as most important
to the decision to migrate that were selected by the fewest
respondents (less than 1% of the sample) were as follows:
how certain ethnic groups are treated in the workplace (se-
lected by 5 respondents); the risk of contracting a serious
illness in the workplace (10 respondents); and respect from
management to whom you report (10 respondents). The
living conditions identified by the fewest respondents as
among their three most important in deciding to migrate
were as follows: government efforts to mitigate gender in-
equity (7 respondents); how certain ethnic groups (or
castes) are treated in your country in general (15 respon-
dents); and government efforts to mitigate ethnic inequity
(16 respondents).
The stakeholders we interviewed spoke of salaries, pre-
ferred locations for working, and the nature of work in
Indian hospitals as migration causes. Opportunities for
specialist training and subsequent professional develop-
ment were also noted as limited in India, especially for
doctors. In the case of medicine, some stakeholders
suggested that the rise of domestic contract-based (tem-
porary) employment in the domestic public service en-
couraged doctors to look outside the country for better
conditions of employment. The appointment of doctors
on contract in the public service was originally thought
to help keep costs down, but according to one respond-
ent, this approach “did the greatest harm to the profes-
sion and the medical future of India”(P23, Hospital
Medical Head).
Fig. 3 Frequency seeking migration information from recruiters (Source Health Professional Migration Survey, n= 1719)
Fig. 4 Frequency seeking migration information from personal contacts (Source Health Professional Migration Survey, n= 1719)
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Occupation-specific factors include lower salaries,
whether in the public or private sectors, poor working
/employment conditions, and the lack of government jobs
(which were consistently seen as the most desirable type
of employment). These factors were noted for their role in
influencing nurses in particular to consider emigration;
“the fact is that private sector nursing salaries are very low
and service conditions are poor. Government jobs are not
available. Therefore nurses migrate”(P10, Academic Dir-
ector, p. 86). Although economic factors are typically cast
in the literature as the most important reasons for emigra-
tion [5], in specific reference to nurses, one respondent
noted that “the reasons for migration are not always
purely financial…(nurses) look for safety, security and re-
spect and dignity of their profession”(P49, Nursing Associ-
ation Representative). There were several indications from
respondents that lack of respect also had a role to play:
“nurses are not treated very well in Indian hospitals, as
compared to, say, USA or UK. They are not given the re-
spect or the responsibilities which they could shoulder”
(P38, Academic Director). In general, the low level of
professional autonomy nurses experience in India adds to
the desirability of migration opportunities to locations
where professional development and skills promotion is
available [30]; as one respondent noted, “The scheme of
Nurse Practitioners, which exists in the USA, is not avail-
able in India”(P38, Academic Director).
Our scoping report and the stakeholders indicated that
rising education costs and the international orientation
of health worker training enhanced the proclivity for
health worker migration. Although health professional
training is primarily intended for Indian practice,
whether in the public or private sector, the curriculum
materials used in Indian training institutes our research
team visited were often international English language.
There is also a conscious acknowledgement of the need
to prepare health workers for potential international ex-
perience: “We want people to migrate, but we don’t have
a conscious policy to [promote that]. …[But] people will
migrate and this is better for the state if they migrate
with a better bargaining position”(R2, Senior Depart-
ment of Health Official). Indeed, in some educational
Fig. 5 Migration interest among health professionals (Source Health Professional Migration Survey, n= 1719)
Table 3 Odds ratio estimates for respondents reporting having applied for foreign work permit
Kerala Punjab
Effect Point estimate 95% confidence limits Point estimate 95% confidence limits
Dentist vs. nurse 0.421 0.136 1.301 N/A N/A N/A
Pharmacist vs. nurse 0.230 0.066 0.808 2.037 0.883 4.696
Generalist physician vs. nurse 0.103 0.023 0.461 1.646 0.602 4.495
Midwife vs. nurse 1.653 0.197 13.853 N/A N/A N/A
Specialist physician vs. nurse 0.726 0.312 1.687 1.730 0.744 4.021
Physiotherapist vs. nurse 0.272 0.034 2.184 N/A N/A N/A
Radiographer vs. nurse 1.384 0.483 3.965 N/A N/A N/A
Male vs. female 2.522 1.389 4.578 1.667 0.797 3.488
Age 25–34 vs. age <24 0.930 0.460 1.882 1.426 0.621 3.275
Age 35–44 vs. age <24 0.512 0.196 1.335 2.568 0.808 8.166
Age 45+ vs. age <24 0.561 0.192 1.644 3.544 1.105 11.365
Married or living together vs. all others 0.799 0.426 1.499 0.508 0.257 1.002
N/A insufficient numbers and/or data to include in model
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institutions, training was presented as specifically and
exclusively geared toward overseas employment: “In X
[training college], the whole effort was towards training
nurses for foreign jobs”(P10, Academic Director). In
these cases, entering the health care profession can itself
be explicitly used as a means of accessing international
migration opportunities.
Health professionals are often trained in an environment
where employment options are regularly cast in both the
national and international context; as one key stakeholder
stated: “Outside India such as Western countries, even in
Sri Lanka and Pakistan, pharmacists are highly recognized
and given equal importance as doctors. We can say that
many migrate because of issues of lack of job satisfaction
and recognition by the society than for money”(R6,
Health Professional Association Representative).
Some stakeholders indicated that many doctors seek
overseas opportunities not because of poor working condi-
tions and salary in India but in order to gain post-graduate
training. They suggested that India’s highly bureaucratized
public health sector creates limited opportunities for phy-
sicians to enroll in specialized training, which then delays
the candidate’s progression through the ranks. “Migration
is not an issue. It is not about migration, doctors go for a
postgraduate position once passed out (graduated) in
abroad. So more than migration we can say that they are
going for higher studies that cause the shortage”(R4, Se-
nior Government Department of Health Official). Some
stakeholders indicated that those who gain specialist train-
ing are more likely to move into the private sector once
trained. These observations reveal that doctors and nurses
engage in international migration for different reasons.
Table 4 Odds ratio estimates for respondents reporting having applied for a foreign residence
Kerala Punjab
Effect Point estimate 95% confidence limits Point estimate 95% confidence limits
Dentist vs. nurse 0.528 0.269 1.036 0.468 0.126 1.740
Pharmacist vs. nurse 0.511 0.281 0.929 1.638 0.603 4.451
Generalist physician vs. nurse 0.100 0.041 0.244 1.694 0.732 3.920
Midwife vs. nurse 0.913 0.189 4.395 N/A N/A N/A
Specialist physician vs. nurse 0.536 0.300 0.959 1.978 0.860 4.550
Physiotherapist vs. nurse 0.354 0.099 1.262 N/A N/A N/A
Radiographer vs. nurse 1.512 0.730 3.132 N/A N/A N/A
Male vs. female 1.527 1.022 2.279 1.712 0.821 3.571
Age 25–34 vs. age <24 1.116 0.694 1.795 1.371 0.611 3.076
Age 35–44 vs. age <24 0.629 0.343 1.155 2.425 0.813 7.232
Age 45+ vs. age <24 0.532 0.260 1.090 4.168 1.340 12.965
Married or living together vs. all others 0.430 0.137 1.356 0.520 0.271 0.999
Table 5 Odds ratio estimates for respondents reporting having applied for a foreign practice license
Kerala Punjab
Effect Point estimate 95% confidence limits Point estimate 95% confidence limits
Dentist vs. nurse 0.655 0.332 1.293 0.587 0.126 1.740
Pharmacist vs. nurse 0.577 0.311 1.071 1.772 0.876 4.239
Generalist physician vs. nurse 0.182 0.088 0.376 1.515 0.669 4.215
Midwife vs. nurse 0.450 0.055 3.656 N/A N/A N/A
Specialist physician vs. nurse 0.496 0.265 0.926 1.812 0.815 4.394
Physiotherapist vs. nurse 1.897 0.701 5.136 N/A N/A N/A
Radiographer vs. nurse 1.633 0.776 3.437 N/A N/A N/A
Male vs. female 1.245 0.822 1.884 1.700 0.774 3.536
Age 25–34 vs. age <24 0.772 0.461 1.293 1.398 0.642 3.158
Age 35–44 vs. age <24 0.662 0.358 1.224 2.446 0.819 7.937
Age 45+ vs. age <24 0.538 0.263 1.101 3.785 1.291 11.980
Married or living together vs. all others 1.482 0.937 2.343 0.519 0.288 1.082
N/A insufficient numbers and/or data to include in model
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In terms of the central governments’handling of migra-
tion, the general perspective of most stakeholders can be
summed up in the following comment: “(the) Government
of India and Government of Kerala are not promoting mi-
grating. We are not stopping also, it is a passive thing”
(R9, Senior Government Official). The idea that there was
no active governmental promotion of migration, nor was
it prevented, was a widely held opinion among our re-
spondents. As one stakeholder noted, this policy “neutral-
ity”needs to be contextualized in terms of the economic
benefit the Indian state will potentially receive from mi-
gration: “Government of India does not have any policy of
trying to put limits on migration or trying to insist on
minimum domestic service. The reason is that govern-
ment feels the need for foreign exchange which these
nurses will earn”(P10, Academic Director). The discourse
of state benefits derived from health worker migration op-
poses the idea of the state attempting to prevent out-
migration and suggests that a multiplicity of viewpoints
exist in India regarding the outmigration of health
workers. These positions compete for influence over local
and central state policy debates.
The burden of personal debt that was taken on to gain
training was also seen to feed the compulsion to go
overseas, particularly in the case of nurses. To quote one
respondent’s summary reasons for migration, “the major
attraction for most of those who migrate …is to pay back
loans taken for their education”(P5, Academic Director).
This compulsion was driven by policy decisions that liber-
alized the health educational market, as was explained to
us by an academic director in Delhi: “So long as the gov-
ernment keeps on giving No-Objection-Certificates to pri-
vate businessmen to open Nursing Colleges, and they
keep on charging very high fees from the Nursing stu-
dents, how else can the students recover the cost of train-
ing except by going abroad?”(P10, Academic Director).
How has this changed over time?
Trends in migration of Indian health workers were
thought to be changing. One stakeholder explained that
there was a big exodus of nurses around 1993 and again
between 2003 and 2009, but now, these flows have been
reduced “to a trickle.”These particular flows were di-
rected at the USA, Australia, Singapore, and the Middle
East. Stakeholders in general agreed that the migration
flow has reduced: “Migration of nurses to USA, UK,
Australia, Canada has stopped since they have closed the
doors. Even in the Middle East, they are starting their
own nursing colleges, so maybe migration there will also
come down”(P54, Senior Government Department of
Health Official).
Reasons for this “change”or apparent decrease in
health worker migration flows were offered including
the lack of availability of US visas at the time of research,
although one respondent did note “We are hearing that,
migration of nurses to USA may be allowed once again,
but there is nothing official yet”(P49, Nursing Associ-
ation Representative). Other reasons for a decline in the
scale of migration included reduced job opportunities in
light of the Global Financial Crisis, improvement of
nurses’salaries in India following recent Pay Commis-
sion reviews, and improvement in working conditions.
Consequences of health worker migration
Health workforce shortages: is migration the cause?
Health bureaucrats revealed general ambivalence about
whether international migration is the major factor be-
hind health workforce shortages; “if nurses go abroad, it
is certainly a loss. But the numbers are not alarming”
(P10, Academic Director). Rather, the benefits from re-
mittances were seen to compensate for outmigration
and stakeholders, as well as our scoping report indicated
that the training system (especially in the private sector)
was perceived as producing an excess of skilled health
workers for this purpose. This reveals the presence of
competing observations about the nature of the problem
(if it is a “problem”at all) in the case of the international
migration of health workers from India.
During the time of our research, specific information
about health workforce shortages indicated that in Punjab,
the required posts for doctors at the primary level of health
care were filled, but 249 specialist doctor positions (sur-
geons, OB & GY (sic), physicians and pediatricians) at the
secondary Community Health Centre level were not filled
[39]. In Kerala, an excess supply of health workers was evi-
dent “(In) India, yes, [there are adequate employment op-
portunities but] in Kerala, not yet. Because Kerala cannot
absorb the number of personnel it trains”(R2, Senior Gov-
ernment Department of Health Official). Nevertheless, a
shortfall of specialists at CHCs was acknowledged in the
Kerala case. These specific shortfalls in both Kerala and
Punjab may be linked to the bureaucratic delays evident in
the public sector appointment process of senior physicians,
something key stakeholders also commented on.
The sectoral and regional health workforce density dif-
ferences in evidence across India partly explain the am-
bivalent position of health bureaucrats when asked to
comment on the influence of HWM on workforce short-
ages nationally. Stakeholders highlighted that vacancies
often reflect not shortages but distribution issues be-
tween the public and private sectors and across rural
and urban locations. Some stakeholders bemoaned par-
ticularly the lack of vacancies for nurses in the govern-
ment sector, indicating that government sector jobs are
readily filled. One stakeholder reported encouraging
health professionals to migrate rather than to go to the
private sector in India, arguing that “private sector ser-
vice conditions are very poor…if they get some better
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opportunities [overseas], stay there for some time and
[then] come back”(R5, Regulatory Body Representative).
Perceptions of shortages of nurses nonetheless were
held and explained by “(the) mismatch between need and
availability in the rural and urban India”(P28, Hospital
Medical Head). This speaks to a characteristic of shortages
common to many countries, the maldistribution of health
workers in rural and remote areas, and failures to improve
conditions which could help to retain skilled health
workers in rural and remote areas. International migration
is generally understood as only one part of the issue of
overall maldistribution of health workers across India, es-
pecially in regard to the lack of physician specialists and
poor rural health service provision.
The mismatch between effective system infrastructure
and the health workforce mix is also part of the calculus
of shortages: there may be enough doctors to serve the
population, but “the doctors are terribly overworked and
we would want to have more infrastructure and then
more doctors”(P28, Hospital Medical Head). Shortages
or excesses in one occupational category will certainly
influence the workload of the other: “We have not cre-
ated enough posts for nurses. Moreover when a doctor
has to serve in an area where there is no nurse staff,
[this results in a] heavy work load that actually aggra-
vates the situation”(R4, Senior Government Department
of Health Official).
Some stakeholders saw migration as less relevant to
health workforce shortages in terms of quantity but
more about quality, where migration results in the loss
of valued skills and experience: “All the first rank
holders and really good people are serving for other
countries. That should not happen. There is no shortage
but there is a quality problem”(R19, Regulatory Body
Representative). Some stakeholders indicated they had
no trouble hiring health workers, “I can recruit Junior
Resident doctors, Senior Resident doctors and also posts
of nursing orderlies and sweepers etc. as per government
policy. We fill up these posts on a regular basis through
open advertisements or on contract or on ad-hoc basis
through walk-in interviews”(P23, Hospital Medical
Head), and another said, “We get a lot of applications
for these vacant posts; we do not experience any short-
age of applicants”(P28, Hospital Medical Head).
For others, however, structural bureaucratic bottle-
necks in the public sector represented another dimen-
sion of health workforce distribution that complicated
effective workforce deployment. Some stakeholders
noted that bureaucratic issues slowed down approval for
some positions in the public (government) sector leading
to both the perception and reality of shortages: “(there
are) some specialties like Anaesthesia, Medicine and
Radiology in which we are not able to get Junior Regis-
trars (JR) and Senior Registrar (SR) doctors despite
repeated efforts. We have suggested hiring them on
part-time basis by Government as per market rates, -
but approval is yet to come”(P23, Hospital Medical
Head). Many doctors, despite good working conditions
found in the public sector, were reported not to leave
the country, but rather to move to the private sector.
According to one stakeholder, “A significant number of
senior registrar (SR) doctors leave to join (the) private
sector but a larger number of junior registrar (JR) doc-
tors migrate from private sector to public sector, and in
the public sector, from smaller hospitals to bigger hospi-
tals”(P23, Hospital Medical Head).
Loss of national investment
Some respondents thought that any migration of health
workers from India produced negative effects for the
country, but always positive benefits for destination
countries, as the literature also suggests: “when these
people migrate, the foreign country gets trained persons
free of cost and our country loses skills which have been
developed at public cost”(P28, Hospital Medical Head).
There was also evident concern that the international
orientation of some sectors of health worker training
would become crisis ridden as overseas opportunities
dry up, leading to structural flaws in India’s increasingly
internationally orientated health education system:
“We are going to enter a huge crisis in the nursing
education sector. The markets outside have dried up,
even in the Gulf. …Many of these kids have studied
by taking on loans, they are not going to get
employment. The market will bid down their wage to
very low. Then political pressure can then help me
create some more posts for the nurses, but social
ramifications will be very worse”(R2, Senior
Government Department of Health Official).
Other perspectives of migration were those that pro-
duced negative impacts at the personal/familial level,
rarely spoken about in the literature, including the fate
of children and elderly parents who may remain in India
and marital distress linked to migration and temporary
separation: “(It’s) difficult to take care of parents. Marital
ties may weaken, even sometimes leading to divorce.”
(P49, Nursing Association Representatives).
Deskilling and loss of value through global circulation
One of the concerns consistently raised in the literature is
that health professionals who migrate from India may
practice below their skill level [40], and this is particularly
germane for nurses, raising important gender consider-
ations [41, 42]. Some stakeholders offered limited insight
on deskilling. One mentioned that nurses already overseas
preparing for or awaiting the results of their nursing exams
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would take lower category jobs (P2, Academic Director).
Another stakeholder thought that there were structural
barriers to Indians rising beyond middle-management level
in the USA, and another that Indian General Nursing and
Midwifery (GNM) Diploma holders were being treated
only as Assistant Nurses in Saudi Arabia. Bilateral engage-
ments between India and major receiving markets did ap-
pear to address deskilling processes, resulting in a policy
response: “In Saudi Arabia, Indian GNMs were being
treated as Assistant Nurses. The reason was that nurses
from the Philippines argued that since they were at B.Sc.
level, they should be one level above our GNMs. The Saudi
government agreed. Ultimately, the Government of India
took a decision to allow only B.Sc. nurses to migrate to
Saudi Arabia.”(P10, Academic Director).
Return migration and re-integration
Lack of knowledge and data with regard to health
worker migration prevented an accurate assessment at
the time of research regarding where health workers
were migrating, if they returned and what happened to
them after they returned. Some stakeholders suggested
there was very little evidence of return migration, and
our survey findings supported this, since only 1.9% of
the nurse respondents and less than 1% of the other
health professions were return migrants. Others did
comment on return migration, mostly in reference to
nurses: “People go to USA and UK for professional ad-
vancement. There is no data that they came back”(R40,
Hospital Medical Head). Migration was seen as part of a
life cycle decision that included marriage and permanent
migration: “Generally unmarried girls go abroad, they
marry and settle abroad. So there is very little return mi-
gration ”(P46, Academic Director). Others reported that
nurses who go to the United Kingdom of Great Britain
and Northern Ireland, the United States of America,
Canada, and Australia “do not usually come back. They
take their families with them”(P10, Academic Director).
Another thought that, “So many nurses want to come
back from USA and UK,”(P54, Senior Government De-
partment of Health Official) but did not indicate
whether they ever did fulfill their wish to return. Unless
they move onto other destinations, return migration was
seen as inevitable for those in the Middle East; “nurses
who migrate to Middle Eastern countries are not settling
there. They come back.”(P49, Nursing Association
Representative).
The practice and pattern of return migration did emerge
as distinct for doctors versus nurses, with one respondent
noting the favorable mobility that doctors can receive
from the state: “Some state governments give doctors five
years sabbatical to work abroad, so they are assured of
jobs when they return”(P54, Senior Government Depart-
ment of Health Official). However, all returning health
worker migrants can face restrictions in re-entering their
profession. Although anyone, including returning mi-
grants, can apply for advertised vacancies (in the public
sector), there is an age limit: 30 years for nurses and
50 years for doctors. For instance, the Government of
India appoints General Duty Medical Officers (GDMOs)
through the Union Public Service Commission but there
is an upper age limit of 35 years (P28, Hospital Medical
Head). Overseas experience and credentials may not be
recognized by the professional regulators and employers,
as noted in the case of nurses: “Returning nurses struggle
a lot. They cannot get back their government jobs and
have to accept lower paid private sector jobs”(P49, Nurs-
ing Association Representative).
Return to India is not always a gratifying experience, as
one stakeholder expressed, “The situation of nurses
returning, usually from the Middle East, is pitiable. Many
of them have gained valuable experience but the govern-
ment does not absorb them. Corporate hospitals may give
them jobs because they are experienced nurses and the
hospitals need some stable staff”(P10, Academic Dir-
ector). Re-integration into the Indian health sector after a
period abroad provides its own challenges: “it is not easy
for those who return from abroad to get adjusted easily. I
think the major challenges for re-integration are adjust-
ment issues to a different way of life and medical practice,
lack of networking, different profile and attitudes of pa-
tients etc.”(P23, Hospital Medical Head). Although it ap-
pears that there is relatively little return migration, there is
some evidence in the literature, affirmed by our stake-
holders, that suggests that some Indian health profes-
sionals are willing to return “if they can get appropriate
position(s)”; otherwise, “a few corporate hospitals are
accepting returnees. Some of these returnees continue to
make brief visits abroad”(P2, Academic Director). Some
stakeholders also noted that pharmacists who returned
were able to operate independent chemist shops or
pharmacies.
Overall, the examination of return migration was con-
strained by a limited sample of return migrant respondents.
The limited survey responses indicate that of all health pro-
fessionals, nurses are nearly twice as likely to be return mi-
grants. In these cases, the main policy challenge appears to
be re-integration. Some stakeholders indicate that most re-
turnees go into the private sector where employment con-
ditions are worse than the public sector and that generally,
despite the suggestion that medical tourism might be hiring
health professionals with western medicine exposure, our
survey suggested that return migrant numbers were not
significant. Clearly, the issue of return migration and pro-
fessional re-integration into practice for health professionals
are important. Such policy issues are vital to understand if
we want to examine how “brain circulation”might actually
be achieved in the case of the Indian health system [43].
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Policy responses to health worker migration
Our stakeholders traced many of the health workforce
challenges they identified to a lack of policy more so
than migration. For example, the perceived shortage of
nurses in India is because “authorities (are) not serious
about quick expansion of nursing education”(P46, Aca-
demic Director). As another commented, “State level
policies are poor”insomuch as “there is no training re-
serve nor any organization to undertake the training
load of so many workers”(P23, Hospital Medical Head).
Many seemed resigned to the lack of such policy atten-
tion, noting as possible explanation that “the Govern-
ment of India does not object to foreign agencies and
governments recruiting Indians for foreign jobs”(P28,
Hospital Medical Head). This also suggests that if the
government was concerned about shortages and/or mi-
gration of health workers, policy to suppress recruitment
and uptake of migration opportunities might be a sens-
ible place to start.
1
Although many of the stakeholders held positions that
should suggest involvement in policy consultation, few
indicated any formal policy engagement. They nonethe-
less offered several thoughts about policy responses to
health worker migration at different levels of governance
which we categorize here as the national/meso- and
macro-/global levels.
National meso-level policies
Addressing the Push Factors
Suggestions to address push factors included improved
salaries in the public sector, although recent increases in
public sector pay for health workers appeared to some
stakeholders to be having the desired effect: “salary in
government sector is much higher than earlier. So
people are less eager to go abroad. The first priority is to
get a job in the government sector. Only if that fails do
they go for migration”(P46, Academic Director). How-
ever, reductions in the availability of jobs in the public
sector, combined with a decline in migration, meant that
“nurses work for lower pay and with poor working con-
ditions in the private sector”(P46, Academic Director).
According to those who discussed nurses, with the ex-
ception of National (central) Pay Commission interven-
tions that determine nurses’pay structures and other
conditions of services, there has been little in the way of
administrative response to requests to improve working
conditions and professional standards. To address nurs-
ing shortages, there are some indications that the gov-
ernment “tries to increase the number of nurses,”and if
there is a shortage, “the appropriate policy is simply to
train many more nurses”(P38, Academic Director). This
leads to “Government say[ing] that more and more
nursing schools and colleges should be opened.”(P42,
Regulatory Body Representative). Doing so, however,
returns us to a consideration of the privatization, afford-
ability, and quality of nursing education.
Education, training, and return of service
Return of service has long been discussed in the inter-
national literature as one means to ensure that countries
receive some benefit from the state investments they
make in health worker education and training [44]. One
respondent reported that “there is some attempt at Gov-
ernment level to insist that doctors must compulsorily
serve in rural areas for a minimum period. But the pro-
posal is yet to be finalised or implemented”(P28, Hos-
pital Medical Head). This policy suggestion was linked
directly to the expenditures of public money, “if a doctor
has been trained on the basis of government subsidies,
then the person concerned must either refund the
money spent or else must serve for a minimum period.
Subject to these conditions individual freedom of choice
must continue”(P38, Academic Director).
In the case of nursing, private sector employers had
reportedly been confiscating nurses’registration certifi-
cates and/or insisting on a bond period in order to re-
tain their services (P49, Nursing Association). This
practice was ruled illegal by the Supreme Court of India
(ruling no. 527) in 2011. The Trained Nurses Associ-
ation of India (TNAI) proposed a bill on nursing service
conditions that would ban this practice and other types
of service conditions. Policies that ensure mandatory na-
tional return of service were nonetheless seen by some
stakeholders as necessary and justified: “We are spend-
ing so much on training. Those who are migrating must
give an undertaking that they will come back and put at
least some minimum years of service in India”(P17,
Pharmacy Association Representative) (see Fig. 6). On
the other hand, the majority of health workers surveyed
indicated that such policy actions would make no differ-
ence to their migration decisions. However, the second
highest level of health worker survey response does sug-
gest policy actions to manage health worker migration
might make some less likely to migrate, therefore achiev-
ing the presumed policy goal (see Fig. 7).
Mid-level cadres and new models of health care delivery
Alternative models of health care include the use of
mid-level cadres of health workers who perform selected
tasks under supervision. Such work would previously
have been undertaken by highly qualified health profes-
sionals. Some stakeholders saw this occupational re-
structuring as a form of policy response in areas where
shortages of doctors and nurses existed. In India, the use
of mid-level cadres is fairly recent. One respondent ex-
plained, “The proposal to start a 3 year Bachelor of Rural
Health Care is a good idea and it is now under examin-
ation by the Government of India…In the state of
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Chhattisgarh they have a cadre of Rural Medical Assis-
tants. Similarly the state of Assam has Rural Health
Practitioners”(P38, Academic Director) [45]. The same
respondent explained that these qualifications are not
transferable: “these are state-specific solutions and the
graduates of these programmes are not entitled to prac-
tice outside the state concerned.”This also disqualifies
them from migrating internationally as health workers
because their qualifications and training are not transfer-
able. This creates a fairly immobile occupational group
whose qualifications may not be fully transferable across
all Indian states, never mind internationally.
Encouraging return migration
How to encourage return and how to treat returning
migrants poses domestic challenges: “if [returning mi-
grants] are better than their domestic counterparts they
should be paid more, but we should not in general pay
more to a return migrant than to equally capable domes-
tic counterparts”(P38, Academic Director). In the ab-
sence of policy that encourages the return of health
worker migrants to India, “Government should create a
working group to examine the factors contributing to
[such] migration and to find ways of tackling these is-
sues”(P49, Nursing Association Representative).
One policy suggestion related to return migration was
the adoption of exchange programs, as one respondent
explained: “Under these programmes a nurse goes
abroad for a specified period, gets further training as
well as employment for a fixed number of years and
then returns to India”(P5, Academic Director). But, lim-
itations of such international exchanges were pointed
out: “The Western medical technology which some of
the migrant nurses may have learnt to use, cannot al-
ways be adopted in India”(P5, Academic Director).
Global and macro-level policies
At the macro-level, several respondents reported lack of
knowledge or familiarity with regard to international
codes such as the WHO Code, and its predecessors, the
Commonwealth Code or the United Kingdom’s codes
for the National Health Service [46–48]. The same level
of knowledge was also reported for policies that encour-
age return migration or bilateral agreements between
countries. One respondent referred to the “hidden”na-
ture of the World Health Organization and lack of
knowledge of the WHO Code, again suggesting that at
some levels the international body has little visibility.
Another person who did know about the codes was not
able to pass on any knowledge with regard to their ef-
fects, while a third commented on their lack of impact.
Despite some promise that these codes can help to
“streamline the migration process”and that “India
should take active interest”in them (P5, Academic Dir-
ector), another complained that “the codes have no im-
portance in practice. [The] government of India wants
people to migrate because they get foreign exchange”
(P32, Nursing School Representative).
Health workforce data collection policy challenges
The knowledge of migration that our stakeholders
shared was largely drawn from their own personal ex-
perience, and not from sources of official data. The lack
of concrete data and statistics with regard to health
Fig. 6 View of mandatory national and return of service (Source
Health Professional Migration Survey, n= 1719)
Fig. 7 How would government policy effect your migration decisions? (Source Health Professional Migration Survey) n= 1719 each question
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shortages and migration consistently came up as explan-
ation for lack of knowledge and an inability to answer
some of the questions we posed. Routine information on
India’s health workforce suffers from significant limita-
tions [31]. It was a generally held observation that there
is no government data on migration: “Nobody informs
us about migration,”and no agency “is tracking the
movement/migration of doctors and health workers
across the states, regions, sectors or nations”(P17, Phar-
macy Association Representative). The issues of data
and data availability were not discussed extensively by
those we interviewed, and there did not appear to be
interest great enough to advocate for or encourage data
collection at different points in a career trajectory: “No,
why should we keep that [information]? Once they go
out from college they are on their own”(R14, Academic
Director). Some colleges did indicate some approaches
to building limited databases on the location of their
alumnae/i: “We know somewhat about who all have mi-
grated. Other than that we don’t have data. It is quite
difficult. We usually meet through Facebook”(R7, Aca-
demic Director). Another stakeholder noted that the “In-
dian Nursing Council (INC) is working to create a live
register of members”(P49, Nursing Association Repre-
sentative). In general, there was little to suggest much in
the way of collection or coordination of data between
state and national level bodies.
Discussion
This paper offers an analysis of health care worker mi-
gration in terms of perceived causes and demographic
factors associated with migration, an array of perceived
consequences and appropriate policy responses in the
case of India. Our research supports earlier findings re-
garding the migratory causes among Indian health
workers, which includes push factors such as low remu-
neration, poor working conditions and work overload,
concern with status of the profession, and lack of oppor-
tunities for professional advancement [2–6, 38]. Our re-
search offered greater insight regarding the personal
characteristics of those having applied for foreign work
permits and licenses (more males rather than females,
and in Punjab, those not currently married) and in terms
of occupational sector (nurses exhibited higher rates of
interest in migration than other professionals in our sur-
vey). Our research also revealed how the propensity to
migrate varies according to sector-specific factors such
as conditions of domestic employment and specialist
training opportunities (physicians) and global cyclical re-
cruitment trends for specific types of health workers
(pharmacists). The detail our research offers suggests
that determining who is most likely to engage in migra-
tion is a complex interaction of multiple factors shaped
by an increasingly transnational context, this has not
been fully explored in the literature in the case of India
specifically, and for such a wide range of health worker
occupations in general.
Our research highlighted the depth of contradictory
thinking evident within key stakeholder communities
with regard to the perceived influence of international
migration of health workers on national health work-
force issues. Stakeholder perceptions regarding whether
migration caused shortages varied depending on which
occupational group they were involved in and whether
they were commenting on the wellbeing of migrants, ac-
cess to care, or national economic development. The
perceived drivers of migration and return migration for
physicians, pharmacists, and nurses are identified as dis-
tinct, from seeking opportunities for specialist training,
to increasing professional status and quality of life and
responding to fluctuating international demand.
The scoping review concluded that India faces a myr-
iad of challenges with regard to health system strength-
ening and improving basic access to primary health care
in an equitable manner. The size of the population, the
social and health disparities accompanied by demo-
graphic and epidemiological transitions that face this
low- and middle-income developing country, and the
pronounced disparities in access to health care, form the
context in which a highly bureaucratized health system
struggles to coordinate limited resources, including
health human resources. Health worker migration is one
of many factors that can contribute to health workforce
shortages, but retaining health workers emerged as a
lesser consideration for India’s attention [41].
In terms of the consequences of health worker migra-
tion, our research indicates that the government response
to health worker migration at both the state and central
government levels is marked by conflicting perceptions,
something not previously examined in detail in the existing
literature. While no official policies to promote inter-
national migration were identified in our interviews with
key stakeholders, the benefits from migration that accrued
to the state in terms of remittances, and the increasing role
of the private sector in training health professionals for
both domestic and international service, suggest a vested
interest in this process of skills export does exist; this is an
area for further examination as suggested in other studies
[23]. Health worker shortages within India were often ex-
plained as consequences of factors other than migration,
such as urban vs. rural and private vs. public workforce dis-
tribution issues that have been detailed before [11, 12, 25].
Our research, however, also revealed other health work-
force policy failures and bottlenecks that have led to short-
ages and unfilled positions, especially in key specialist
physician/surgeon and health management roles. Some
direct consequences of international migration that were
mentioned by key stakeholders included the social costs of
Walton-Roberts et al. Human Resources for Health (2017) 15:28 Page 14 of 18
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

migration (children and families left behind), the deskilling
of professionals and the lost value that represents, and the
challenge of re-integrating returning health workers into
thedomestichealthsector.
Policy responses to health worker migration were dis-
cussed in terms of the national (meso) and global
(macro) level. Improving the retention of Indian health
professionals through government schemes to improve
pay and conditions have limited influence in a context
where the private sector is increasingly dominant, as has
been detailed in the literature [17, 20, 23]. This lack of
central government influence is most apparent in the
case of nurses in the private sector, which appears to be
less desirable than public sector employment. Likewise,
national state action to increase training spaces and
maintain health worker quality will likely be of limited
consequence under conditions of increased private sec-
tor dominance without improved regulation of health
training across all sectors [20, 23]. Physician-owned hos-
pitals are among the private nursing schools exploiting
nurses. Promoting deeper engagement with an interpro-
fessional health team approach may help to form collab-
orative leadership between these occupational groups,
potentially moving the system toward improved working
conditions for nurses. The creation of new cadres of
health care workers appeared as a solution to certain
health worker shortages, but our research indicates the
quality of this training and its ability to service national
health needs demands further analysis, which would ac-
company recent inquiries on the matter [18, 19]. State
policies to contain migration, such as bonding and re-
turn to service agreements, have been adopted in some
cases, but their success is difficult to determine and in
the case of bonding, has been ruled illegal by the Su-
preme Court of India. Based on our health worker sur-
vey results, the threat of various policies aimed at
controlling migration (such as passport restrictions, in-
creased emigration fees and return of service and na-
tional service) is relatively neutral.
The ability of the central government to exert control
over health worker migration is not an area that has re-
ceived significant research attention, and in light of the
growing dominance of private sector training, any policy
space the central government has in this area will likely
diminish. Promoting return migration and encouraging
international exchange and work experience did emerge
as possible policy options, since they allow for inter-
national career development while maintaining connec-
tion to the domestic workforce. The use of international
health worker mobility policies in order to retain
workers in the long run has not emerged in the litera-
ture, and further research on this approach, and other
forms of bilateral health worker mobility partnerships
and trade in health services agreements, are areas of
interest in terms of state-market policy responses to
health workforce issues.
At the macro-level our key stakeholder interviews sug-
gest there is relatively little knowledge of the Global
Code on health worker recruitment and India’s position
with regard to the Global Code [46–48]. International
discourse on migration (WHO Code) is therefore not
providing leadership. Aligned with relatively weak health
data collection at the national and state levels [19], many
of our stakeholder interviews revealed that the use of
and contribution to any form of universal data collection
was limited and appeared detached from health work-
force planning and decision-making. This suggests that
to assess the magnitude of the migration of health care
professionals from India, the cooperation of destination
country immigration and professional registration data
collection systems is required. Without adequate data, of
course, emerging patterns of health worker migration
cannot be detected, making it more difficult to develop
effective policies to manage migration processes. Per-
haps, the move toward having National Health Work-
force Accounts as part of the recently passed Global
Health Strategy will assist in this regard.
This study was limited by a number of factors. Its geo-
graphical focus was on certain states (Kerala and the
Punjab), which we caution may not represent experi-
ences across India. There were two relatively independ-
ent survey research teams involved in data collection,
and some differences in how the data collection was per-
formed created some interpretive challenges for com-
parative analysis. The study’s cross-sectional design also
precludes the possibility of longitudinal analysis. Our
study however does make reasonable assumptions that
survey and interview respondents knew of what they
spoke and commented knowledgeably on the causes,
consequences, and policy responses regarding health
worker migration from India.
Conclusions
Few studies have examined health worker flows and
their consequences in detail and there has been an al-
most exclusive focus on the migration of medical and
nursing practitioners and a lack of consideration of other
highly skilled health professionals. Research to date has
also given less attention to the range of policy responses
that decision-makers at different levels have either taken
or can select to stem the tide of emigrating health pro-
fessionals or address domestic issues of health human
resources distribution and shortages. This paper, based
on an extensive and systematic scoping review of rele-
vant literature, a health worker survey with 1719 Indian
health professionals and 74 key stakeholder interviews
(KSIs) provides in-depth analysis of these issues. Based
Walton-Roberts et al. Human Resources for Health (2017) 15:28 Page 15 of 18
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

on this research, we offer a number of conclusions
which we cluster around three key points.
First, in addition to the standard economic reasons,
the causes of health worker migration must also be
understood in terms of the career opportunities and
pathways open to the various health occupations; this is
consistent with past research [30, 31, 38]. The negative
consequences of poor planning in career development
opportunities were especially evident in the lack of spe-
cialist training opportunities for physicians. Another fac-
tor that informs migration decisions is security of
tenure, which appears more favorable for nurses and
doctors in government rather than private sector em-
ployment, and appears to suppress the propensity to mi-
gration. Employment conditions in the private sector are
poor for nurses and may encourage migration, in this
case mostly for salary reasons. Doctors, on the other
hand, appear more able to switch between the public
and private sectors, thereby extracting beneficial condi-
tions of employment by staying within India. Pharma-
cists and dentists appear to have benefitted from a
growth in overseas opportunities in the last decade that
have provided improved salary and training conditions
overseas. The focus on career advancement and security
of tenure, rather than just salary, suggests Indian health
workforce planning and retention efforts must focus on
system-wide dimensions of career development and se-
curity, in addition to compensation.
Second, we maintain that what appear to be the conse-
quences of health worker migration are not easily separ-
able from other causal and compounding factors.
Shortages of health workers are evident in certain parts
of the country and in certain specialty areas, but the de-
gree and nature of such shortages are difficult to deter-
mine, and the strength of the relationship of such
shortages to international migration is not clear. Our re-
search suggests that shortages occur more because of
shortcomings in domestic policy on training, recruit-
ment and retention than as a direct consequence of the
international migration of health workers. In these cases,
international migration becomes an aggravating factor in
the lack of staff in rural areas, but it is simplistic to see
the one (international migration) directly causing the
other (staff shortages). Rather, we echo the argument
that international migration should be seen as com-
pounding acute domestic problems in health workforce
distribution [31, 38, 44].
Third, policy responses to health worker migration are
embedded in wider processes aimed at health workforce
management, but overall, there is not a clear policy
agenda to manage or limit health worker migration at ei-
ther state or central levels of government. Health bu-
reaucrats hold conflicting opinions about the need or
desirability of curtailing migration, and schemes that do
place limits on emigration (such as Emigration Clear-
ance Required for women migrants heading to certain
countries) are pitched to address problems other than
health worker shortages, such as dealing with fraudulent
recruiters, securing personal protection or assurance of
the employment rights and protections of emigrant
workers. There are clearly tangible losses of investment
made by the state and households, but within the wider
context of diminishing opportunity structures and more
privatized forms of human capital investment, it is hard
to track where those losses become most acutely held.
Based on the stakeholder interviews, it is fair to ask
whether the Indian central and state governments might
enable the process through their passive acceptance of
health worker migration.
Endnotes
1
Recently, the government of India has curtailed the
migration of nurses to some parts of the Middle East,
but this has been spurred to address complaints of
abuses linked to the private recruitment industry, not
out of a concern about shortages of nurses in India.
http://www.thehindu.com/news/cities/Thiruvanantha-
puram/issue-emigration-clearance-to-nurses-cm-tells-
centre/article7189808.ece.
Abbreviations
B.Sc.: Bachelor of Science; CHC: Community Health Centres; GDMOs: General
Duty Medical Officers; GDP: Gross domestic product; GNMs: General Nursing
and Midwifery Diploma (holders); HIC(s): High-income country (countries);
HRH: Human Resources for Health; HWM: Health worker migration; JR: Junior
Registrars; KSI(s): Key stakeholder interview(s); LMICs: Low- and middle-
income countries; MeSH: Medical subject headings; NHP: National Health
Policy; NRHM: National Rural Health Mission; OB & GY: Obstetricians and
gynecologists; RSBY: Rashtriya Swasthya Bima Yojana; SR: Senior Registrar;
TNAI: Trained Nurses Association of India; WHO: World Health Organization
Acknowledgements
We would like to acknowledge the contribution made by three reviewers
and the editors of Human Resources for Health toward improving earlier
versions of this manuscript, and additional data analysis conducted by Md.
Moniruzzaman.
Funding
The funding source for the study was the Canadian Institutes of Health
Research (Health Services and Policy Research Institute) for the “‘Source
country’perspectives on the migration of highly trained health personnel:
Causes, consequences and responses.”(Funding Reference No: MOP 106493).
CIHR did not participate in any way in the study design, collection, analysis
and interpretation of data, and writing of the manuscript.
Availability of data and materials
The participating countries’dataset(s) supporting the conclusions of this
article are not publicly available to ensure respondents’anonymity in
reporting and confidentiality in participating in the study as per the study’s
ethical requirements.
Authors’contributions
MWR contributed to the conception and design of the paper, interpreted
the data, and drafted and reviewed the article. VR contributed to the design
of the paper, analyzed and interpreted the data, and drafted and reviewed
the article. IR, AS, and SN contributed to the conception and design of the
research, analyzed and interpreted the data, and reviewed the article. PT
Walton-Roberts et al. Human Resources for Health (2017) 15:28 Page 16 of 18
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

acquired and interpreted the data and reviewed the article. RL contributed
to the conception and design of the paper, interpreted the data, and
reviewed the article. CP interpreted the data and reviewed the article. GTM
contributed to the conception of the paper and reviewed the article. AM
contributed to the conception of the paper, analyzed the data, and drafted
and reviewed the article. IB conceived the study, interpreted the data, and
reviewed several drafts of the paper. All authors read and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
The study was approved by the University of Ottawa (Ethics Approval
Certificate numbers H07-10-02H and H07-10-02C). In India, ethics clearance
was granted by the Institute of Development Communication (Punjab) and
the Centre for Development Studies (Kerala).
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Balsillie School of International Affairs, 67 Erb Street West, Waterloo, ON N2L
6C2, Canada.
2
Faculty of Medicine, University of Ottawa, 850 Peter Morand
Crescent, Ottawa, ON K1G 3Z7, Canada.
3
Centre for Development Studies,
Prasanth Nagar, Medical College P.O, Ulloor, Thiruvananthapuram 695 011,
Kerala, India.
4
Centre for the Study of Regional Development, School of
Social Sciences, JNU, Delhi, India.
5
Athiyara Madom Devi Temple Lane,
Vanchiyoor, Thiruvananthapuram 695035, Kerala, India.
6
College of Nursing,
All India Institute of Medical Sciences, New Delhi, India.
7
WHO/PAHO
Collaborating Centre on Health Workforce Planning and Research, Dalhousie
University, 5869 University Avenue, Halifax, Nova Scotia B3H 4R2, Canada.
8
WHO/PAHO Collaborating Centre on Health Workforce Planning and
Research, School of Nursing, Faculty of Health Professions, Dalhousie
University, 5869 University Avenue, Halifax, Nova Scotia B3H 4R2, Canada.
9
School of Epidemiology, Public Health and Preventive Medicine Faculty of
Medicine, University of Ottawa, 850 Peter Morand Crescent, Ottawa, ON K1G
3Z7, Canada.
10
Telfer School of Management, University of Ottawa, 1 Stewart
Street, Ottawa, ON K1N 6N5, Canada.
Received: 15 June 2016 Accepted: 18 March 2017
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