Rebalancing act: promoting an international research agenda on women migrant care workers’ health and rights

Abstract

Using a gendered lens, we examine the balance between the contribution that migrant women make to global economic and social development through their labour, especially in the care and global service economy, with the health impacts and costs incurred by this group of migrants.

Full text

88
6 Rebalancing act: promoting an
international research agenda on
women migrant care workers’ health
and rights
Jenna Hennebry and Margaret Walton-Roberts
Introduction
e feminization of global labour migration is one of the most signicant shifts
in contemporary migration noted by international agencies and scholars. Women
migrants make signicant contributions to the global care and service economy,
yet they face signicant gendered health risks as a result of their global mobility
and performance of this essential ‘care work’. Care work has typically been dened
as the work of looking after the psychological, physical, developmental and emo-
tional needs of one or more people and is often understood through the lens of
intimacy and privatized, often gendered relationships (Raghuram, 2012; Standing,
2001). Numerous structural factors have increased the supply and demand for
migrant care workers, including social policy and austerity-linked restructuring
(Farnsworth and Irving, 2015); the privatization of health services and increase
in health insurance systems (Keane et al., 2002); as well as demographic factors
including aging populations in developed nations and growing youth cohorts with
limited employment opportunities in several less developed nations. ese demo-
graphic and social policy factors are variously aligned with the increasing labour-
force participation of women in the Organisation for Economic Co-operation
and Development (OECD) countries (Jaumotte, 2003), and the feminization of
international migration (Chammartin, 2002). e interaction of these processes
has led to growing numbers of migrant care workers (with a range of skill levels
and in a range of occupations within the sector) entering the global labour market
while they face decreased rights protections and increased health risks linked to
precarious employment in sectors with high levels of physical and mental health
risks.
Using a gendered lens, we examine the balance between the contribution that
migrant women make to global economic and social development through their
labour, especially in the care and global service economy, with the health impacts
and costs incurred by this group of migrants. In the context of the 2030 Agenda
for Sustainable Development, where addressing inequalities is a core underpin-
ning principle guiding the sustainable development goals (SDGs), it is imperative

REBALANCING ACT 89
that the social and health costs of migration be part of the rebalancing act needed
to foster human development for all. We examine how women migrant work-
ers’ (WMWs) abilities to access health services and exercise their rights to social
protection are restricted by the conditions of their migration, and the policy frame-
works that structure this mobility. We then examine policy initiatives that have
attempted to address these lapses at the regional, national and multilateral level.
Finally, we review what is needed to advance an international research agenda for
gender, rights and health for migrant women, including enhanced data gathering
and sharing pertaining to women’s migration, and new policy approaches to rights’
protections and health care access.
Our chapter builds on and extends the eld of intersectional research examining
women migrants’ health (Guruge and Khanlou, 2004), as well as the more extensive
research eld that examines health and health service access by immigrant class,
be it refugees, permanent immigrants or temporary workers (Lindert et al., 2009;
Preibisch and Hennebry, 2011; Subedi and Rosenberg, 2014). Additionally, we build
on research that has shown immigrants’ variable access to health services can be
explained by multiple factors, be they administrative, political or cultural (Bollini
and Siem, 1995).
The feminization of migration and the global care crisis
In the twenty-rst century, there are three critical and interlinked demographic
shifts occurring that are acting to reshape the nature of care and social reproduc-
tion. First, a period of unprecedented population aging is ongoing; by 2050, one
in every ve people throughout the world is projected to be 60 years or older
(UN-DESA, 2007). In many rapidly aging states, like Germany, the labour pool is
expected to shrink from 45 million to 29 million people by 2050 (Oberoi, 2015).
Second, fertility rates are reducing to the point where many developed nations will
face population decline without immigration. ird, women have an increasing
role in the paid labour market. In developing countries, the manufacturing work-
force is one-third to one-fth female. Along with other variables, these factors are
leading to the formulation of a care decit in many countries in both private and
institutional contexts, which is increasingly addressed using migrant care labour. In
2016, about 47 per cent of migrants were women, and personal care and domestic
workers accounted for over 2.43 million migrants, or about 10 per cent of the total;
the main source countries were the Philippines, China and India (Hennebry et al,
2016b). In addition to domestic and personal care workers, skilled immigrants in
health and allied professions contribute to the global circulation of care workers.
For instance, foreign nurses represented 10.7 per cent of the combined nursing
workforce in the OECD, equal to a total of 711,877 nurses (OECD, 2007, p.165).
e source countries for nurses remains similar to domestic workers, with the
migratory ow of overseas nurses mainly from the Philippines, India, China and
sub-Saharan African countries to developed countries in the Global North (OECD,
2007, p.173).

90 A RESEARCH AGENDA FOR MIGRATION AND HEALTH
Migrant women are disproportionally integrated into these global care circula-
tions, and have become increasingly vital to global economies as their care earnings
result in higher proportions of remittances being submitted to countries of origin.
Women migrants have been shown as more likely to send a greater proportion of
their earnings home (despite earning less than men), and women have been shown
to be more likely to invest in human capital factors that support family well-being
and sustainable development (such as education) (Hennebry et al., 2017; Osaki,
1999). Research has also shown, however, how migration and remittance patterns
can reect norms of gendered income inequality, so that in some cases men still
remit more because they earn more (Semyonov and Gorodzeisky, 2005). Moreover,
empirical research on migration, remittances and development has argued that we
need to understand the role and inuence of the range of actors included beyond
migrants themselves; overgeneralization tends to erase the contextual diversity that
surrounds the gender–migration–development nexus (where remittances usually
play a signicant role), and nally that there is a tendency to overgeneralize with
regard to conceptualizing the migration–development nexus in terms of gender
(van Naerssen et al., 2015). We maintain that such overgeneralizations can be
addressed in part through a critical examination of migrant women and health
in terms of their contribution to care-related employment (including direct and
indirect health care provision) and their own access to health care as migrants. is
focus allows us to draw out one of the key paradoxes accompanying the feminiza-
tion of migration: that women migrants engaged in providing care worldwide do so
under conditions that deny them that same care.
e deciency of social programmes and policies around care and migration are
root issues that contextualize the increased engagement (paid and non-paid) of
women in that sector. Over the last two decades, research on care and caring
has produced important feminist analysis of global political-economy and social
policy change during a period of neoliberal transformation, which has provided the
context for what scholars have interpreted as a ‘care crisis’, particularly in child,
elder and other forms of long-term care (Mandell, 2010; Williams, 2014). e use
of temporary migration policies for domestic and care workers, for example in the
Middle East, Singapore, Taiwan and Hong Kong,1 attracts mostly female migrant
care workers, and has been one way this care crisis has been addressed (Le Go,
2016; Peng, 2017). e increasing incorporation of migrant women (typically from
the Global South) into the provision of personal and health services to populations
in relatively wealthier nations has been understood through several concepts, and
one of most inuential is the global care chain (GCC). e GCC, which uses the
idea of commodity chains to reect the extraction of ‘surplus care’ and its transfer
up the economic hierarchy (Hochschild, 2001; Parreñas, 2000), illuminates the
numerous factors that compel women to migrate as one response to existing social
welfare/care decits they experience. Core to the idea of the GCC is the lack of wel-
fare and public services in both origin and destination countries that contributes to
the demand and supply for global-care migrant workers. Many states have limited
responsibility in the provision of care through social policies and programmes
(for instance, the USA limited maternity leave provisions; inadequate spending on

REBALANCING ACT 91
elder care in parts of the UK and European Union). is has led to private house-
holds bearing care-related responsibilities (Orozco, 2009). For countries where
women are increasingly participating in the labour market –or in places where
hired domestic workers symbolize auence or social status – households seek
out migrant women to undertake care responsibilities (Yeates, 2009). Arguably,
the lack of state-provisioned care services fosters demand for migrant women in
these societies because women entering the workforce cannot full the domestic
duties that are socially ascribed to them (Yeates, 2009). Central to the GCC is
that migration, in the provision of care abroad, creates an absence of care in the
origin country. is absence is usually lled by other local women, but rarely does
it lead to a shift in the gender balance of domestic responsibility (Yeates, 2009).
In these cases, the absence of social policies around care, and the intransigence of
the gendered division of household and care labour, leads to care responsibilities
being extended to kin or other local women, who are usually in a position of relative
weaker socio-economic standing.
e existence of care chains signals the absence or lack of state policies around
social welfare and protection vis-à-vis care in both sending and receiving states,
and creates the lever for deeper exploitation of already existing spatial and socio-
economic inequalities along transnational chains marked by variable socio-spatial
dierences. e increasing mobility of women migrants in the provision of care and
other services is a clear feature of the contemporary global economy. Women are
key in the provision of care in health, social and domestic sectors of the economy
but, paradoxically, in the provision of health and social care for others, their own
health is often undermined. We turn to a deeper analysis of this reality in the
following sections where we review health risks in general for migrant women,
explore three specic occupational sectors (domestic work, health care and sex
work), and then oer comments on research gaps and policy approaches that might
advance a rebalancing of migrant care workers’ own access to care, health and
greater protection.
Health risks and access to care for women migrants
e nancial, emotional and physical costs incurred by WMWs at every stage of
the migration process, are supposedly oset by the nancial benets that migration
can bring in the long term. However, associated work risks place many migrant
women into potentially vulnerable situations, particularly as they are anxious to
oset the costs of their migration with nancial benets they may accrue from
employment. In the desire to meet this goal, migrant women may have to work in
conditions that are detrimental to their safety, physical and mental health and well-
being. Conditions of work, such as social isolation, co-existence and proximity with
employers, expose these women to increased risks to sexual violence, abuse and
harassment in the workplace (Edmunds et al., 2011; McLaughlin, 2008; Villarejo,
2003). Numerous studies have documented the health risks, barriers to accessing
health care and insurance systems (from basic care needs to sexual and reproductive

92 A RESEARCH AGENDA FOR MIGRATION AND HEALTH
health care, workplace safety insurance, supplemental and long-term care needs)
and adverse living conditions of WMWs across a range of sectors, from agriculture
(Encalada Grez, 2011; Hellio, 2008, 2014; Hennebry et al., 2010; McLaughlin, 2009;
Preibisch and Encalada Grez, 2010) to manufacturing (Livingston, 2004; Sassen,
2000) and care work (Parreñas, 2001; Villarejo, 2003). e conditions that struc-
ture WMWs’ experiences have impacts for their mental and physical health, with
many experiencing long-term mental health challenges stemming from abuse and/
or isolation and family separation; sexual and reproductive health issues stem-
ming from sexual or reproductive violence (such as forced abortion or forced work
while pregnant) and/or lack of sucient access to reproductive health care; and
other physical injuries or illnesses due to workplace hazards (such as burns from
cooking, exposure to harsh chemicals used while cleaning without personal protec-
tive equipment (PPE) or musculoskeletal strain from general workplace hazards,
exhaustion or other impacts from physical labour or physical abuse). With employ-
ers typically mediating access to health care, migrant workers may fear reprimands
from employers in the form of loss of current or future employment, wages, and
so on. is, coupled with stringent eligibility requirements, lack of access to trans-
portation, information, translation or insurance, means that WMWs encounter
numerous barriers to accessing care to address such health needs.
Below we outline some of the key issues with respect to migrant women’s health
and human rights among three groups of care workers particularly represented
by WMWs: domestic workers, health care workers and sex-trade workers. Each
of these occupations can broadly be dened as care work, which can take the form
of both physical and emotional labour, occurring in both public and private space,
and is commonly considered to be an extension of essentialized feminine roles
(even when men occupy such positions). Care work often occurs in less regulated
sectors, is often inected with legal uncertainties and highly contingent on wom-
en’s relationships with their employers (Hennebry et al., 2017). Care work tends
towards increased commoditization, is highly precarious, usually undervalued and
underpaid, and seen to be an extension of ‘natural’ feminine traits and behaviours
(England, 2005).
Domestic care workers
Migrant care workers face deskilling and barriers to credential recognition, as well
as isolation and exploitation that is particularly acute, since domestic care workers
are often working in employers’ homes with whom they have tied work permits
(Pratt, 1999). As such, domestic care workers are typically controlled closely by an
employer in their own home, who may require domestic workers to do extra work
outside of their job description or require them to work overtime. e relation-
ship between employer and domestic/care worker has been identied as a major
problem in domestic worker schemes, as the power imbalance between workers
and employers in such unregulated and close quarters leads to greater possibilities
of abuse and exploitation. Further, employers often mediate or control access to
health care and may monitor the activities of their employees.

REBALANCING ACT 93
For example, Filipino non-governmental organizations (NGOs) have highlighted
violations of sexual and reproductive rights particularly among domestic workers,
with cases of migrants being deported on being found pregnant or HIV positive
(Encinas-Franco, 2016, p.36). e particular conditions of work in the private set-
tings where care work is most often undertaken have deep implications for the
health of these women. Further, women’s health is tied to their availability in seek-
ing out health care outside the home, access to which may be restricted because of
the onerous expectations put forth by employers, employer surveillance or lack of
access to transportation. Employers may incorrectly assess whether a worker needs
care, and women may be unable to request care out of embarrassment or expecta-
tions, or fear of loss of employment or other reprisals (for example, verbal abuse,
docking pay or requiring additional hours of work).
e extensive emotional nature of care work specically, which often involves
intimate care of young children, can manifest in women feeling exhausted, while
impacting their physical and psychological health (Parreñas, 2001). Conversely,
workers who provide care services for the elderly generally live-in with their
employers and may have more decision-making ability due to their employer’s
dependency on their assistance (Parreñas, 2001). Similar to live-in domestic child-
care workers, migrant women who care for the elderly have very little time o as
they are constantly expected to provide their employers with care throughout the
day (and sometimes also overnight). As many of these caregivers live in the homes
of their employers, they not only experience extended work hours, but may also feel
psychological isolation (Parreñas, 2001).
Despite the known occurrences of such conditions, the sector remains largely
unregulated. Instead of ensuring labour rights through labour law, regulating
industry practices and reprimanding employers for infractions, governments oper-
ate as though this particular industry were self-regulatory, an increasingly common
theme among destination countries. Indeed, even when there has been active state
involvement aimed at protecting these workers, the sector has proven dicult to
reach. For example, despite the active role of the Philippines to protect its workers
abroad through bilateral agreements, there have been numerous documented cases
of exploitation and abuse, such as the recent instances of violence and abuse of
overseas domestic workers in countries such as Saudi Arabia (Varia, 2014).
In response to the gendered risks encountered by women migrants, governments
have imposed restrictions on mobility, such as deployment bans, which are gener-
ally imposed on women, and are meant to serve as ‘protective policies’ (Carling,
2005). Several highly documented cases of exploitation and tracking of Nepali
migrant women workers have emerged over the last decades and the Nepali state
has reacted to these cases by periodically deploying travel bans that deny exit
permits to women migrants. Between 1997 and 2008, the government of Nepal
enacted at least ten dierent migration policies targeting women, from complete
to partial migrant bans (Grossman-ompson, 2016). Similarly, in May 2015 the
Indonesian government banned migrant domestic workers from travelling to work

94 A RESEARCH AGENDA FOR MIGRATION AND HEALTH
in 21 dierent Middle Eastern countries after the execution of two Indonesian
workers found guilty of murder in Saudi Arabia (Walden, 2017). e Philippines
has also utilized deployment bans on domestic migrant workers to countries that
the government deems unsafe, and this has included Saudi Arabia, Lebanon, and
other countries in the Middle East and the Gulf (Campbell, 2013).
Health care workers
As we embark towards the second decade of the millennium, nursing shortages
have become prevalent on a global scale. A 2010 joint World Health Organization
(WHO) and International Council of Nurses publication estimated the global pro-
jected shortage of full-time nurses and midwives will reach 2.8 million by 2015
(Lane et al., 2010). In the USA alone, the care sector is expected to grow by 70
per cent over the next ten years (Malcolm, 2012). As the International Labour
Organization’s (ILO) World Employment and Social Outlook 2015 underscores,
similar trends can be observed globally (Maybud, 2015). Women migrants in
the care economy increasingly ll care decits left by lack of aordable public
care services and health sector cutbacks that are not responding to the reduc-
tion in national women undertaking reproductive tasks. Nurse migration from
the Philippines, for example, responds to a demand for skilled medical specialists
in destination countries. By bringing in nurses from the Philippines, destination
countries gain vital skills without any prior investment in these migrants’ human
capital. In the meantime, the Philippines, which has invested in the education of
these individuals, is left with a gap in its labour force (Lorenzo et al., 2007).
e international migration of health professionals is not a new phenomenon;
however, owing to the global nursing shortage in many countries in the Global
North, the stock of nurses living and working overseas has increased over the past
two decades.2 A WHO (2017) high-level dialogue on health worker migration con-
rmed substantial interregional – South to South and North to South – mobility
of health workers, including increased use of temporary migration, and concern
regarding the oversupply of nurses in some countries that is not well connected
to labour market demands. Leading producers of nurses for international mar-
kets include India and the Philippines (ompson and Walton-Roberts, 2018), but
other Global South nations, especially sub-Saharan African nations, have provided
nurses for the global market. e Philippines, for example, has invested heavily in
nursing schools, becoming the world’s leading source country for internationally
educated nurses (IENs), with estimates of over 250,000 Philippine-trained nurses
employed across over 30 countries worldwide since 2000 (Marcus et al., 2014).
Nursing is increasingly characterized as a mobile profession (Kingma, 2006). For
nurse migrants, the direction and scope of migratory ows are reliably determined
by a set of ‘push’ and ‘pull’ motivators (Connell, 2010). Political, social and economic
insecurities, substandard working conditions and undesirable quality of living are
commonly attributed factors that drive IENs to emigrate. On the other hand, IENs
choose their overseas destination based on a set of factors that determine a coun-

REBALANCING ACT 95
try’s level of attractiveness to migrants, which includes their opportunities to gain
higher income, standard of living and prospects for career advancement (Home,
2011). In much of the Global North, particularly in the USA, the UK, Canada,
Australia, Ireland and New Zealand, hiring IENs is regarded as a ‘quick x’ solution
to curtail the eects of nursing shortages and to increase labour market exibility
(Valiani, 2012).
Correspondingly, in several countries of the Global South, especially the Philippines,
India, China and the newly independent states of the former Soviet Union, there is
a deliberate eort to overproduce nurses for overseas employment (Brush and
Sochalski, 2007). It is, however, often the private education sector that provides this
export-directed training, resulting in lower-quality training and poor regulatory
oversight (ompson and Walton-Roberts, 2018). Of considerable concern is that
the countries lowest down on the chain are unable to replace the outmigration
of their nurses, which exacerbates their own chronic nursing shortage (Yeates,
2010). is produces a ‘perverse subsidy’, perpetuating a pattern in which poorer
countries invest in the training of health professionals who migrate to provide care
to developed nations (Mackintosh et al., 2006).
Despite nursing shortages, IENs who have gained entry into the Global North
experience many barriers to practising nursing. In Canada, these barriers can be
considered structural, as they manifest due to the incongruences between the
immigration processes that grant entry and work visas for IENs, and the provincial
licensing processes that allow them to practise nursing in Canada (Walton-Roberts
and Hennebry, 2019). e eect of these barriers is adverse and systematic, pre-
venting many IENs from re-establishing their professional careers (Blythe et al.,
2009). e assessment of an IEN’s foreign credentials (the evaluation of education
equivalency and skills qualications) is often cited as one of the most common
barriers that signicantly delays or prevents IENs from completing their licensure
process altogether (Kolawole, 2009). IENs who are already residing in Canada are
being eectively deskilled if they desire but fail to complete their nursing licensure.
Similarly, IENs who entered the previously named Live-In Caregiver Programme
(now called the Caregiver Programme) are also considered eectively to engage
in ‘devalued carework in informal, unregulated employment conditions’ (Walton-
Roberts and Hennebry, 2012, p.5).
Deskilling also occurs when nurses, unable to complete their licensure and to prac-
tise nursing, enter alternative careers within the health care eld. Anecdotally,
common alternative career options for IENs include the personal support worker
(also known as personal aide, home support workers or personal care attendant)
profession – currently a non-regulated, entry-level occupation in the health
care eld that does not require signicant education or training. Forging greater
cooperation and mutual recognition of international credentials between national
jurisdictions creates greater mobility for individuals and facilitates exibility in
health human resources planning. But internationalizing nursing credentials does
pose greater challenges for national health care systems to maintain integrity of

96 A RESEARCH AGENDA FOR MIGRATION AND HEALTH
training levels and public safety. Further research is needed to assess the impact
of the combined eects of recent policy and regulatory changes in order to better
understand its inuence on the Canadian labour force, the nursing profession as a
whole (including deskilling, standards, and so on), the health care sector (including
impacts on patient care), and the inuence on the health and well-being of IENs
and their families.
Research on the experiences of IENs has identied how their health and well-being
is negatively inuenced by the structural barriers they face in the labour market
and, even when employed, cases of discrimination in shift and task allocation,
violent and discriminatory interactions with patients and co-workers occurs and
takes a mental and physical toll (Dicicco-Bloom, 2004; Hagey et al, 2001).
Sex trade workers
From feminist and care perspectives, sex work is key to social reproduction both in
terms of sex-aective services, the maintenance of social systems and the structures
that reinforce them. For example, overworked Japanese businessmen and Asian
migrant construction workers represent industrial systems reliant on sex work-
ers to provide sexual services. Sex work has been conceptualized as an important
part of the global economy (Constable, 2009; Parreñas, 2011), such that ‘track
in women and girls for the purpose of prostitution may be seen as one aspect
of a transnational transfer of sex-aective labor from low-income areas to high-
income areas, to ll gaps which cannot be lled by indigenous labor’ (Truong,
1996, p.36). Yet, global estimates of this sector are particularly dicult – and in
fact, controversial – to obtain with accuracy. e lack of accuracy stems in part
from the underregulated, informality of the sector, which is therefore poorly and
inconsistently measured and captured by ocial statistics and typical sources of
labour market data; while the controversy stems from the reality that the produc-
tion of population-size estimates, and mapping the places where sex workers live
and work, has the potential to be a direct, very serious threat to sex workers’ rights
to be free from discrimination, to privacy, and freedom from arbitrary interference,
and so on (NSWP, 2015).
Migrant workers in the sex trade face particularly high risks of physical violence
and sexual assault, sexually transmitted infections and pregnancy, all of which pose
major consequences for their physical and mental health. For example, the overall
prevalence of HIV among female sex workers in 50 countries is 12 per cent higher
than in the general population of women; the probability for female sex workers
of getting HIV is 13.5 higher than that of women not involved in sex work (Baral
et al., 2012). ere are many reasons for this, such as unsafe working conditions,
unequal access to health services, stigma and discrimination, underregulation, and
so on. Indeed, work in the sex industry is typically unregulated and migrant women
engaged in work in other sectors (such as domestic work) may nd themselves
engaged in sex work, particularly if they have been tracked. e sector is char-
acterized by informality and invisibility (as is the case with domestic work), and in

REBALANCING ACT 97
some cases sex work is happening within the private sphere, inside apartments or
informal brothels, not on the street or inside entertainment businesses or clubs.
Yet, while care/domestic work operates along a continuum between informal to
fully regulated, and is generally sanctioned by the state, tracking for forced labour
and sexual labour are always done informally and therefore have serious conse-
quences for employer–employee relationships. Even though people working in this
sector have fundamental human rights – including non-discrimination – freedom
of employment and social security, health and safety, and labour laws tend not to
apply to this sector, and workers in this sector are not eligible for supplementary
health insurance For migrant women in this sector, there is a high likelihood that
they are working without accurate work permits, or they may have no documenta-
tion whatsoever.
Overall, for migrant women working in the sex trade (whether by force or by
choice), their health, safety and personal security are all at risk while working
and, in most cases, workers will not be able to access sucient health care or
health insurance systems when they need care. Further, these workers are unable
to address long-term health issues or support themselves if they are injured due to
their work, since workplace safety insurance and disability are non-existent in this
sector. Sexual and reproductive health care is particularly important for this group
and, in many cases, access is further impacted by stigma.
Rebalancing the scales: challenging the creation of ‘vulnerable’
women migrants
In both rhetoric and practice, so much of what has structured women’s migra-
tion has served to perpetuate gendered migration pathways, and articulate women
migrants as vulnerable subjects – who are framed as inherently vulnerable to
exploitation and abuse. Despite the feminization of migration, migration govern-
ance tends to be ‘gender-blind’ – ignoring the gendered realities and risks for
WMWs, and leaving the gender inequality inherent in this regime unaddressed
(Hennebry et al., 2017). Further, in many cases, the institutional response of the
state with regards to the rights and needs of women migrants reproduce inequal-
ity among men and women rather than contributing to resolve it. For example,
when implementing policies pertaining to the access of justice for migrant women,
rather than protecting the victim, they revictimize them and promote corruption
(Andión, 2011; Sánchez Matus and Nobara, 2011).
Further, access to migration pathways that lead directly to permanent residency
are often limited for women, who may lack credentials or capital necessary to meet
selection criteria due to inequality in countries of origin, among other factors.
ose who can, access temporary ‘regular’ labour migration pathways; these path-
ways tend to channel women into gendered occupations such as caregivers, clean-
ers, service/sales clerks and entertainers, occupations that are typically low skilled,
low waged, with high levels of precarity, and low levels of social protection– often

98 A RESEARCH AGENDA FOR MIGRATION AND HEALTH
in sectors without consistent collective bargaining rights (agriculture, care work).
Temporary labour migration visa schemes also tend to embed prolonged family
separation, and can have nancial and social costs that can resonate for future
generations.
Lack of access to education, discrimination in labour markets, weak social protec-
tion systems and insucient access to childcare, lack of property rights, gender-
based violence and many other manifestations of gender inequality are drivers of
migration. For example, in Nepal, a 57.4 per cent literacy rate means that work
prospects for many women remain limited to agriculture and domestic work (both
low paying, or unvalued work) (Sijapati et al., 2015). Among women in the Nepalese
labour force, only 8.3 per cent are paid for their work (Acharya, 2014) and women
have particularly poor access to social protection. Migration as a response to such
factors heightens precarity and creates conditions prone to exploitation and abuse.
Unlike most permanent immigration systems, labour migration pathways pro-
vide alternative modes of entry and durations of stay (such as through work-visa
regimes or managed temporary migration programmes) and serve to channel
women migrants into gendered occupations, and create conditions that perpetuate
precarity and gender inequality. Managed bilateral or multilateral labour migration
agreements have become state’s preferred options to maintain orderly ows of such
forms of labour migration, but remain largely gender blind and neglect human
rights concerns (Hennebry et al., 2015). In addition, they often limit mobility rights
in countries of destination, and lock WMWs into gendered occupations character-
ized by deskilling, poorly protected labour rights, and high risk of exploitation and
abuse.
Even when migrant women’s rights are central to international policy frameworks,
the outcomes are often contradictory. For example, one of the few international
agreements on migrant protection, the Palermo Protocol, is aimed to prevent traf-
cking in women and children and posits that those engaged in sex work or in forced
labour under deceitful circumstances are open to violation of human security. e
protocol was purposefully made vague, and laid out in such a way that state legis-
latures would be able to exibly work it into existing law enforcement scenarios,
including border security and prosecution of trackers. is is in opposition to the
International Convention on the Protection of the Rights of All Migrant Workers
and Members of eir Families (ICRMW), which states shied away from because
it was so specic on human rights. Instead, the protocol espouses a protection-
from-harm norm where it is up to states to protect women and children from the
harm created by outside forces. is is perplexing, given that behaviours of states
towards migrant populations are themselves harmful (that is, securitized practices
at the border). e Palermo Protocol, to a considerable degree, legitimizes state
practices that not only control but also nd and expel vulnerable migrant popula-
tions. It was ratied and entered into force in 2003, before the ICRMW had been
ratied, despite the latter having been approved by the UN General Assembly ten
years prior to the approval of the former. e juxtaposition between these two

REBALANCING ACT 99
conventions signals friction at the global level between the neoliberal, economistic
perspective and the human rights, social development perspective. e signatories
to tracking protocols far exceed those pertaining to human rights of migrant
workers. e ICRMW and ILO Conventions (Nos. 97, 143 and 189) have had little
to no traction on states.
Evidenced-based policy changes are needed to address these shortcomings, to alle-
viate the health risks and barriers, and meet the needs of women migrants. To do
so will require a rethinking of the care economy and of social protection to accom-
modate transnational workers. From a gender perspective, this will require better
information and data on the unique experiences and needs of women in migration
to inform the development of transnational social protection systems (for exam-
ple, through the creation of portable health care insurance schemes, transnational
health insurance systems or bilateral agreements are particularly important mecha-
nisms) (Hennebry et al., 2016a; Hennebry et al., 2016b).
Many sending countries such as the Philippines have established bilateral agree-
ments with destination countries for their populations (for example, the Philippines
has signed 107 bilateral labour agreements (BLAs) with 79 countries: 49 general
agreements on employment, welfare and cooperation (mostly on health profession-
als and domestic workers), and 13 agreements on social security. ese agreements
oer potential avenues for integrating access to health care under employment
contracts or labour migration programmes, and also for facilitating access to care
upon return and for migrant families (Hennebry, et al., 2016a). Yet few of such
agreements address access to health care for migrants when working in countries
of destination, including emergency, supplemental, and long-term care through
national and local-level policy instruments.
Research gaps, needs and research agenda
Methods of data col lection and measurement serve to categorize migrant ows,
and are often used to determine migrants’ access to services, or which rights and
protections they may be granted by which governing bodies; they are also used to
shape policies and practices of governing that can directly aect migrant rights. e
kind of informa tion, and how it is used/shared, has wide-ranging consequences,
both positive and negative. Missing data is particularly important. Generally, there
is incomplete and inconsistent data on labour migration and indicators of decent
work, and it is not all sex-disaggregated. Further, some data are not being col-
lected and shared that would be valuable towards ensuring decent work for WMWs
(for example, access to health care services, accidents or injuries experienced by
migrant workers, labour disputes, work permit denials, entry refusals, return, infor-
mal work, policy monitoring, and so on).
e largest complete source of data comes from the OECD, which provides com-
parable numbers of labour migrants by sex in its Database on Immi grants in OECD

100 A RESEARCH AGENDA FOR MIGRATION AND HEALTH
Countries (DIOC). It includes stocks of WMWs in 100 countries for the year 2000
from all countries in the world. It also includes the occupation of these workers,
using the ISCO-88 classication system, their education level and their age, occupa-
tions and origins of WMWs. e DIOC has more detailed versions available solely
for OECD countries only in 2000 and 2006 by gender. e ILO has global labour
migration estimates by sex and economic sector between 1987–2008, but these are
only available for 140 countries, which, in turn, are missing the vast majority of their
observations (Maybud, 2015). But these data do not suciently address labour-force
participation by skill level and gender, and most fail to capture temporary migrants
on work permits of temporary visas. Even fewer data sources provide information
on health access, risks, status and care needs of migrant care workers.
Given these shortcomings, there is a general need for not just more data, but better
data on the gendered and intersectional dimensions of migrant care work, as well
as the specic health outcomes and impacts for migrant workers and their families
guided by the framing of the SDGs. Research must aim to strengthen our under-
standing of the way in which inequality and health intersect across countries for
migrant women. More research is needed to factor in the long-term health impacts,
including the mental health of migrants and their families, and access to long-term
care and compensation, if we are to fully comprehend the human and social costs
of such migration.
To enable such research, scholars and advocates must push governments to col-
lect, share and utilize gender-disaggregated data, in ways that protect the rights of
migrants and support research on gendered aspects of migration, including experi-
ences of sexual and gender-based violence (SGBV), precarious employment and
informal work, and access to information, among other areas. It is important that
data are collected in a manner that protects the privacy of individuals, particu-
larly with respect to health and education data (for example, data cannot be used
to refuse essential health care or education for all migrants regardless of status,
including maternal health care).
ere is a need for ongoing gender-responsive evaluation of migration policies and
practices that impact health care migrants, in partnership with women migrants
and civil society organizations (for example, a Gender-Migration Commission).
In particular, more evaluative studies are needed to examine the extent to which
policies, programmes and regulations, ranging from bilateral agreements to
family reunication and credential recognition, impact the economic and social
lives of WMWs with an emphasis on their health and well-being. For example: do
BLAs include health care rights protections for WMWs? What are possible port-
able health care insurance models? How do labour migration programmes or visa
schemes align with international instruments as they pertain to WMWs’ health (for
example, CEDAW, GR No. 26, WHO, and others that pertain to health)?
Whilst much of the focus of research, particularly that carried out by international
organizations, has been placed on migrant contributions to countries of origin,

REBALANCING ACT 101
there has been little analysis of the migration and development nexus in rela-
tion to the contributions of migrant women workers to host economies, and more
specically their contributions to health care systems. Economic modelling on
the nancial contribution of migrant care workers to global care economy would
provide valuable information that could better inform governments and interna-
tional organizations, such as those who attend the Global Forum on Migration and
Development where nurse migration is often presented for its ‘win-win’ outcomes.
In addition, there are economic and social benets that host countries gain as a
result of their women and men being available to participate in the productive
labour market, at the same time as balancing work and family responsibilities, in
increasingly ageing societies. More attention and evidence of the value added by
migrant workers to care economies is particularly pressing in the context of grow-
ing global care decits.
Conclusion
Women migrants face gendered risks of exploitation and abuse throughout migra-
tion, gendered conditions of work, pay inequity, poor levels of social protection
and barriers to accessing health care, labour and human rights – all of which
have consequences for their health and well-being, and hinder eorts to alleviate
gender inequality and realize sustainable development. WMWs across the sectors
discussed in this chapter face particularly adverse impacts on their mental health,
and their sexual and reproductive health – yet in the majority of cases migrant
workers are not eligible for or face considerable barriers to accessing adequate care
at all stages of migration (for instance, pre-departure, transit, employment, return
and integration).
Numerous international frameworks are useful levers to encourage states to recog-
nize migrant health needs and to protect the right to health for all. e situation of
migrant care workers commonly contravenes relevant international human rights
standards, including the ILO Convention 189 concerning decent work for domestic
workers. e Committee on the Elimination of Racial Discrimination (CERD), in its
General Recommendation No. 30 (2004) on non-citizens, and the Committee on
Economic, Social and Cultural Rights (CESC), in its General Comment No. 14 (2000)
on the right to the highest attainable standard of health, both stress that state parties
should respect the right of non-citizens to an adequate standard of physical and
mental health by, inter alia, refraining from denying or limiting their access to preven-
tive, curative and palliative care and services. Indeed, numerous other instruments
can be invoked to further encourage states to live up to obligations to protect migrant
health: the 1965 International Convention on the Elimination of All Forms of Racial
Discrimination: art. 5 (e) (iv); the 1966 International Covenant on Economic, Social
and Cultural Rights: art. 12, General Comment No. 20; the 1979 Convention on the
Elimination of All Forms of Discrimination against Women (CEDAW): arts. 11 (1)
(f), 12 and 14 (2) (b) and General Recommendation No. 26; the 1989 Convention on

102 A RESEARCH AGENDA FOR MIGRATION AND HEALTH
the Rights of the Child: art. 24; the 1990 ICRMW: arts. 28, 43 (e) and 45 (c); and the
2006 Convention on the Rights of Persons with Disabilities: art. 25.
To encourage states to live up to such international commitments, it is vital that
gender-responsive research and data be collected and be used to inform the devel-
opment of gender-responsive migration policy and practices; this is an important
step towards rebalancing the scales to better support the health and social protec-
tion rights of migrant women.
NOTES
1 In Hong Kong, Singapore and Taiwan, where the governments have opted for private family solutions for care,
much of childcare and elder care is nevertheless being outsourced to domestic and care workers. All the three coun-
tries have reformed their immigration policies to enable families to secure foreign domestic or care workers. Both
Singapore and Hong Kong have had long histories of using foreign migrant workers to ll labour shortages. As well,
all three countries share similar ocial national rhetoric of multi-ethnic and multicultural society, and therefore,
have little or no aversion to importing foreign care workers, as long as they do not remain as long-term residents.
Social and cultural norms towards using non-familial domestic workers are also more widespread in these three
countries than in Japan and Korea. In the case of Taiwan, the historical cross-straight tension has created signicant
anti-mainlander sentiments in that country that despite ethnic, language and cultural dierences, South Asian care
workers are more preferred than their co-ethnic Chinese care workers from the mainland (Peng, 2017).
2 For example, nursing is one of the fastest growing occupations in the USA – the Bureau of Labor Statistics antici-
pates that438,100 new jobs (Occupational Outlook Handbook, 2018) for registered nurses will be created in the
USA by 2026. To ll many of these jobs, it will likely be necessary to hire more foreign-trained nurses, which in 2016
already held about15 per centof all registered nursing positions (Hohn et al., 2016). In other countries that percent-
age is even higher:18.2 per centof nurses in Australia were foreign trained in 2016 (up from 14 per cent in 2009),
compared to 26.7 per cent in New Zealand (up from 14.7 per cent in 2002) (Health Workforce Migration, 2019). In
the Arab monarchies of the Gulf Cooperation Council (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United
Arab Emirates), the share of foreign nurses was as high as79 per centin 2008 (Trines, 2018).
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