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‘Source’ Country Perspectives on the Migration of Highly Trained Health Workers: Findings from Jamaica

Author(s) Benjamin Waysome1, Gail Tomblin Murphy2, Adrian MacKenzie3, Rowena Palmer 4, Joan Guy-Walker 5, Annette Elliott Rose6, Ivy Bourgeault7, Ronald Labonte8
Affiliation(s) 1Strategic Human Resource Management, Jamaica Ministry of Health, Kingston, Jamaica, 2WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 3WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 4Strategic Human Resources Planning, Jamaica Ministry of Health, Kingston, Jamaica, 5Human Resource Management and Development, Jamaica Ministry of Health, Kingston, Jamaica, 6WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 7School of Health Sciences, University of Ottawa, Ottawa, Canada, 8Faculty of Medicine, University of Ottawa, Ottawa, Canada
Country - ies of focus Global, Jamaica
Relevant to the conference tracks Advocacy and Communication
Summary Although migration of human resources for health (HRH) is common, the consequences of it for ‘source’ countries are poorly understood, as are the range of strategies implemented to manage these consequences. A study of ‘source’ country perspectives on HRH migration, funded by the Canadian Institutes of Health Research, was conducted in India, Jamaica, the Philippines and South Africa to address this gap. This paper reports the findings from Jamaica, where HRH migration is common, and the causes of it are numerous, long-standing, and systemic. Several strategies have been implemented to address the consequences of HRH emigration from Jamaica, however their impacts have not been studied.
Background The migration of highly skilled health professionals from developing to developed nations has increased dramatically in the last ten years in response to a range of social, economic and political factors. The consequences of this shift in human resources for health (HRH) can be of critical importance to the overall sustainability of health systems in many of these ‘source’ countries, and have become much more salient in the ongoing debate about the reliance of some high-income countries on health workers who migrate from low- and middle-income countries. Few studies have examined these trends and their consequences from a comparative approach; those that have typically focus on ‘macro-‘level health indicators which do not allow for a broader investigation of the range of impacts HRH migration may have on patients, providers and health systems. Further, existing evidence is almost exclusively limited to physicians and nurses without considering the roles of other highly skilled health professionals who are also critical to the sustainability of developing health systems. Research to date has also given less attention to the range of responses that various policy decision-makers can and have undertaken to stem the tide of emigrating workers, and on their respective impacts.
Objectives To help to address the above gaps in evidence, a study was undertaken to examine the causes, consequences and responses to HRH migration from four ‘source’ countries – India, Jamaica, the Philippines, and South Africa. Although designed, initiated and overseen by a team of Canadian researchers, the study was largely driven by partners ‘on the ground’ in each of the four participating countries.The research questions the study sought to answer include:
(1) What is the present picture of /recent historic trends in the migration of highly skilled health personnel from Jamaica, the Philippines, India, and South Africa? (a) Who is migrating, how, and why? (b) What are the levels and impacts of return migration? (2) What, according to various stakeholders ‘on the ground’ in these source countries, are the most critical consequences of the migration of highly skilled health workers? (3) What is the range of policy responses that have been considered, proposed and implemented to address the critical causes and consequences of health worker migration from these countries, and what have been some of the outcomes of these responses?In addition to physicians and nurses, each participating country selected two additional categories of HRH to be the focus of their investigations. The purpose of this presentation is to share the study’s findings from Jamaica, where the additional professions selected were midwives and dental auxiliaries
Methodology The study built on a long-standing successful HRH research partnership between Dalhousie University and the Jamaica Ministry of Health. There were three data collection activities used to address the research questions: a scoping review, key informant interviews, and a survey of Jamaica’s dental auxiliaries, midwives, nurses and physicians. The scoping review identified and synthesized the published peer-reviewed and grey literature on Jamaica as it pertained to the research questions. The initial draft of the scoping review was completed by Canadian members of the research team, reviewed by Jamaican stakeholders for completeness and accuracy, and then updated to address identified gaps. Twenty seven key informants, representing Jamaica’s Ministry of Health, regional health authorities (RHAs), professional colleges and associations, private and public hospitals, universities, the Pan American Health Organization, and the Statistical Institute of Jamaica, were interviewed by the Jamaican study coordinator. The interviews were transcribed, validated by the interviewees, and then subjected to thematic analysis with NVivo 10. The survey of health care professionals was administered using both web  and paper based versions. Respondents could choose their desired format. Survey data were subjected to descriptive and regression analysis using SAS 9.2.Preliminary findings from the scoping review and qualitative and quantitative analyses were presented at a deliberative forum at the University of the West Indies (UWI) campus outside Kingston, Jamaica. Participants represented Jamaica’s Ministry of Health, Ministry of Labour and Social Security, Ministry of National Security, and Ministry of Foreign Affairs, each of the four targeted health professions, the RHAs, UWI, private hospitals, Passport and Immigration Services, the Statistical Institute of Jamaica and the Planning Institute of Jamaica. Participants validated the study findings and deliberated several potential strategies to mitigate the negative impacts of migration on Jamaica’s health care system. These findings were subsequently shared with representatives of the other participating countries at an international forum to identify common challenges and potential solutions.
Results Data on HRH migration are not systematically captured in Jamaica. Migration rates for physicians are estimated at between 31% and 58%, and 66% for nurses. Over one third of respondents from each profession reported that it was very likely they would emigrate within the next five years.Asked why they would emigrate, the top three working conditions-related reasons were income, infrastructure at work, and lack of opportunity for advancement. The top three living conditions-related reasons for migrating were cost of living, public infrastructure, and the quality of consumer goods. Interviewees frequently cited an outdated cadre system as being a barrier to employing necessary personnel, and to advancement for those who are employed. Twenty two percent of respondents reported experiencing some unemployment in the past five years. Fifteen percent of respondents described their current economic situation as “Good” or better and 23% described it as “Poor”. Regression analyses indicated that, after controlling for respondents’ age, gender, profession, years in practice, source of funding for training, and main sector of work (public vs. private), only age was a significant predictor of respondents’ intention to migrate. Older respondents were less likely to report an intention to migrate.Respondents reported being much more likely to receive or make inquiries about working abroad through colleagues in other countries than through recruitment agencies. One third of respondents reported having applied to write the licensing exam for their profession in another country.

Eleven percent of respondents reported having worked in their profession in another country, mostly other Caribbean countries, and returning. Most of these respondents reported being unsure whether their returns were permanent.

Interviewees reported that HRH who migrate tend to be more experienced, which reduces the leadership and mentoring skills available to those who remain. Respondents described international HRH migration as having a more negative impact than rural to urban or public to private sector migration. Eighty percent of respondents said they would send money home to Jamaica if they did migrate. Remittances from all Jamaicans living abroad are estimated at $2B USD or 1/7th of Jamaica’s GDP.

Jamaica has implemented a number of domestic and international strategies to mitigate the negative impacts of HRH migration. However, the impacts of these programs are unknown.

Conclusion Although its current health information systems preclude a precise quantification of the extent of HRH migration, it is clear that migration is very common among Jamaica’s health care personnel. It is also clear from published literature as well as the study participants that the causes of migration in Jamaica are numerous, long-standing, and systemic. Unfortunately, deeper understanding of the causes and consequences of migration, as well as the various strategies implemented to mitigate those consequences, is hindered by a variety of factors. These include weak health information systems (HIS) and infrequent policy evaluation. Recent efforts by Jamaica’s Ministry of Health, in collaboration with other partners, to strengthen its HIS, update its HRH cadre, and increase its capacity for HRH research and policy evaluation may help to address these issues.The study was limited by a low response rate to the survey of health personnel. There were 361 respondents to the survey. Although accurate data on the number of licensed health personnel currently in Jamaica are not available, the estimated size of the potential respondent pool across the four targeted professions is just under 6,000. This makes for a response rate of less than 10%. That said, the findings of the study were validated by a range of Jamaican stakeholders as being consistent with their experience. Further, it was noted by participants at the international forum that many of the findings from Jamaica were consistent with those from the other participating ‘source’ countries. This indicates that its results have national and global validity, strengthening the case for their incorporation into Jamaica’s HRH policy.

Connecting Policy and Practice using Needs-Based HRH and Health Care Service Planning: Partnership between Zambia and Canada.

Author(s) Fastone Goma1, Gail Tomblin Murphy2, Adrian MacKenzie3, Gogi Greeley 4, Selestine Nzala 5, Miriam Libetwa6, Fred Montpetit7, Kenneth Rockwood8
Affiliation(s) 1School of Medicine, University of Zambia, Lusaka, Zambia, 2WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 3WHO/PAHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, Halifax, Canada, 4Department of Health and Social Services, Government of Nunavut, Iqaluit, Canada, 5School of Medicine, University of Zambia, Lusaka, Zambia, 6HRH Directorate, Zambia Ministry of Health, Lusaka, Zambia, 7Department of Health and Social Services, Government of Nunavut, Iqaluit, Canada, 8School of Medicine, Dalhousie University, Halifax, Canada
Country - ies of focus Canada,Zambia
Relevant to the conference tracks Advocacy and Communication
Summary In the midst of a global human resources for health (HRH) crisis, researchers and decision-makers are seeking new and innovative evidence-based strategies for HRH planning. For several years, Canadian and Zambian researchers and policy and decision-makers have been working to adapt a needs-based approach to develop service-based strategies and tools for HRH planning. This approach is based explicitly upon the needs of people, considers the multiple contextual and process factors in the different country contexts, and aims to improve patient, provider and system outcomes.
Background Historically, HRH planning in Canada and Zambia, as in most countries, has been based on supply, use and/or health care expenditures. None of these approaches account for changes in population health needs, provider productivity, or models of care delivery. Since most of Zambia and parts of Canada face critical HRH shortages, it is essential to make the most efficient possible use of these scarce resources in the short term, and to adopt more responsive HRH planning methods in the long term. Service-based HRH planning compares the number and type of services required by populations, given their needs, with the capacity of existing HRH to perform those services. This allows policy makers to collaborate with researchers, educators and providers to identify and compare strategies to address health care system gaps at the level of specific services rather than for particular professions. The unit of analysis used in this framework is the particular health care service that is to be performed by a health care provider to address a certain health care need within the target population. This contrasts with most HRH planning approaches where the health care provider is the unit of analysis.
Objectives The purpose of this paper is to describe the adaptation and application of an analytical framework for service-based HRH planning to different contexts in rural areas of Canada and Zambia. Specific objectives are to: (a) Provide an overview of the analytical framework for service or competency-based HRH planning; (b) Describe the processes used to engage partners in adapting the framework to inform planning in the northern Canadian territory of Nunavut as well as the rural Zambian districts of Chibombo and Gwembe; and (c) Share the lessons learned through collaboration between the researchers and policy and decision-makers across sectors in each application, at the district, provincial/territorial and national levels.
Methodology The framework calls for two quantities to be estimated and compared: how often a particular service is required by the target population (requirements), and how often that service can be performed by the available health workforce (supply). Estimating the first requires the identification of the leading health conditions which drive the need for health care (according to whatever criteria are deemed appropriate by planners in their particular context, such as rates of mortality and/or morbidity), knowledge of the size of the population and the incidence or prevalence of each leading condition within it, the range of health care services required to address each condition, and the frequency with which each service is required by persons with those conditions. Estimating the latter requires data on the size of the available health care workforce as well as their level of participation in it, their levels of activity (e.g. hours worked) and productivity (e.g. cases treated per day), and the prevalence of the competency to perform each service across the existing workforce.The study in Nunavut was funded by Health Canada. The Zambia Study was funded as part of the African Health Systems Initiative. In Zambia, the study was conducted in two rural districts - Gwembe and Chibombo – and considered the needs of their entire populations. In Canada, the study was conducted in the northern territory of Nunavut and was specific to the needs of older adults. In both Zambia and Canada, the research and stakeholder engagement processes were guided by steering committees of local clinicians, educators and policy-makers. Leading health conditions were identified using a combination of administrative data consultations with local stakeholders. Data on population size and the incidence or prevalence of each condition were obtained from administrative sources. The number and type of health care services required to address these conditions were compiled based on published guidelines and then validated by local clinicians. The size and characteristics of the existing health workforces were estimated using a combination of administrative records and a questionnaire administered to health workers in each jurisdiction.
Results The primary health conditions identified in the two Zambian districts were HIV/AIDS and malaria. Although the competencies of the districts’ existing health workforces mostly aligned with these conditions, some substantial gaps were found. The largest gaps identified in both districts were performing laboratory testing and interpreting results, performing diagnostic imaging and interpreting results, taking and interpreting a medical history, performing a physical exam, identifying and diagnosing the illness in question, and assessing eligibility for antiretroviral treatment. In both districts, these services are required very often yet few HWs report feeling competent to perform them – a combination of high need and low supply.Leading conditions among older adults in Nunavut were arthritis, cancer, chronic obstructive pulmonary disease (COPD), diabetes, and hypertension. As in Zambia, while the competencies of Nunavut’s existing health workforce were largely aligned with the health care service needs of its older adults, there were some significant gaps. The largest of these related to ongoing client assessments (mental health, safety, and fall risk), pharmacy services (dispensing, monitoring effectiveness, and addressing polypharmacy issues), and client and family education (related to health promotion and goal setting). Similar to Zambia, these gaps were present because, although required frequently by older adults in Nunavut, relatively few members of the territory’s health workforce have the knowledge, skills and judgement to provide these services.These findings were discussed in deliberative forums in Zambia and Canada with participants representing clinicians, government, educational institutions, regulatory bodies, and health care organizations to ensure their validity and to discuss potential strategies to address the identified gaps. Some suggested solutions for Zambia included targeted professional development in the short term, and, in the long term, increased collaboration between health and education to better align the latter with population health needs, and increased collaboration across sectors to improve living and working conditions for the workforces in these districts. Some strategies suggested for Nunavut included increased dialogue to improve coordination between the home and acute care sectors and between health and education, and expanded use of electronic health records to reduce polypharmacy issues.
Conclusion Although each of the jurisdictions studied possess active, productive and competent health workforces, each also has significant gaps in the services it can provide to meet the health care needs of their populations. The rural and remote locations of the communities in these jurisdictions makes recruitment and retention of highly trained professionals, not limited to HRH, an ongoing challenge. In the short-term, on-site training of existing health workers may be the best approach to address specific competency shortages. In the long term, along with investments in improved infrastructure, continued use of the service-based approach will enhance policy-makers’ ability to align the training, management and deployment of health workforces to meet the needs of its people. This approach provides the flexibility needed to change the composition of health care workforces to align with the changing health needs of the people they serve. The application of the service-based framework in this setting and the relevance of findings to dialogue with policy makers and clinical stakeholders demonstrate its potential utility for other jurisdictions and health care settings in Zambia, Canada, and internationally.The studies in both countries were limited by low numbers of participating health workers, and by the use of self-reported data to measure important concepts such as competence. However, the study’s findings were validated by local steering committees as being consistent with their experiences.In addition to the applications of the service-based approach to HRH, there were a number of mutual learnings from the collaborations between and among researchers and researcher users in these studies. These lessons learned included: 1) the importance of understanding the unique health governance, cultural, economic, historical and political contexts in each country and/or regional setting; 2) the importance of engagement and time to build effective, respectful and trusting partnerships with all stakeholders, across multiple sectors, including researchers and research users; and 3) the importance of capacity building to creating viable processes and strategies for human resources for health and health system sustainability. Most importantly, these connections are key examples of how multi-sectoral partnerships support shared accountability for integrated solutions for HRH planning to advance local and global health.