Gendered Dimensions of

Health Worker Migration:Source Country Perspectives

Why focus on sex/gender?

• Today women outnumber men in trans-global movement, what the

literature speaks of as a feminisation of migration (Camilin, Snow and Hosegood, 2014; Ryan,

2002)

• Women can be active agents in the migration process amongst health

workers, with female nurses globally forming the dominant health worker

migrant group (Brush and Sochalski, 2007).

Why focus on sex/gender?

• Studies of migration has brought attention to the vulnerabilities and exploitation of migrants in general, but with the feminization of migration more so by women, including those in the health workforce (Kofman et al., 2005;

Piper, 2003).

• Although there is knowledge that their sex and gendered roles affect health workers’ reasons for migrating and the impact on their migration experiences, the literature only rarely analyses these important dimensions of health worker migration and their implications for policy responses.

Sex/Gender Based Analysis

• Sex- and Gender-Based Analysis (SGBA) is an approach that systematically examines sex-based (biological) and gender-based (socio-cultural) differences between men, women, boys, girls and gender-diverse people.

• Online SGBA Training Modules (CIHR-IGH)

• GBA+ Online Training (Status of Women)

• Research shows that not paying attention to gender differences, or “gender neutrality,” leads to error, which in turn leads to missed opportunities, misuse of resources and poor outcomes. (Shimmin 2009)

• We applied a framework of sex/gender based analysis (SGBA) and questions that our research team developed to ensure full interrogation of the literature and research data for sex and gender.

Overview of the Literature

• the influence of sex and gender on the typical push/pull theories of international labour market mobility which underpin much migration research and theory.

• the impact of gender on the experiences of migrant health workers in destination countries.

• the gendered impact of health worker migration on formal and informal sectors in source countries, with a particular focus on immigration/emigration policies.

Gendering push-pull models of health worker

migration

• Gender is implicated in the migration decision of health workers through

the gendered discrimination and inequality they experience through

traditional societal attitudes towards female migration (e.g., Adhikari 2013, Byron 1998,

Ryan 2008).

• Gendered transnational social networks, which increase awareness of

migration opportunities, also have a particular influence on female health

workers’ decisions (Nair, 2012; Le Espiritu, 2005; Ryan, 2008 and Hagan, 1998).

Gendering the experiences of migrant health

workers in destination countries

• While men and women experience problems in terms of recognition of their professional credentials in destination countries, the process can be more challenging for women given family responsibilities ascribed through traditional gender roles (Neiterman & Bourgeault, 2015).

• Gender has been shown to shape working conditions of migrant health workers (Bach, 2003 Bagchi, 2001; Batnitzky & McDowell, 2011; ILO, 2005; Hussein, Manthrope and Stevens, 2011; Neiterman &

Bourgeault, 2015; Oikelome & Healy, 2013): women experience lower pay (Bernstein & Shuval, 1999; Ribeiro,

2008); lack of promotion to specialties (Bernstein & Shuval, 1999), and deskilling (Atanackovic &

Bourgeault, 2014; Bourgeault et al., 2010; Hathworne, 2001, O’Brien, 2007).

Gendered impacts of health worker migration

from source countries

• From an individual perspective, migration is thought to bring about gains in

social and professional status and these are accentuated for women.

• With fewer workers in source countries’ health sectors (Jones et al., 2009), some

authors suggest that women workers face increased workload with

attendant stress and low morale (Jones et al., 2005; PAHO, 2001 ).

Source Country Study

• A Canadian-led research team with investigators in the Philippines, South

Africa, Jamaica and India, studying the international migration of HRH from

the same ‘source’ countries gathered and analyzed documentary data and

empirical data generated through in-country surveys with health workers

and international and country-based stakeholder interviews.

Empirical Data

• 1) from scoping reviews of the published literature and policy documents to assess what was known/not known before we proceeded with collecting empirical data;

• 2) in-depth interviews with 144 health worker stakeholders, senior policy officers and health care systems specialists [42 India; 27 Jamaica; 38 Philippines and 37 South Africa]; and

• 3) household and on-line surveys with 4,400 health workers India, South Africa, the Philippines, and Jamaica

South Africa - Literature

• Hull (2010) points out that the career decisions of female nurses are influenced by their personal relationships and networks

• The cultural capital or status that comes with economic security through migration has also helped to improve women’s status which may not exist in her country of origin (Hull, 2010, p. 863).

• The families of migrant nurses also benefit from the opportunities to travel abroad and learn about cultural diversity and histories of other nations (Ntlale & Duma, 2011).

Table 2. Push and pull factors of migration of health workers from South Africa by sex.

Perceived importance of…

Health workers from South Africa

Male n (%)* Female n (%)**

Working conditions

Lack of respect from government

Poor infrastructure

Personal security at work

618 (87.9)

636 (90.5)

627 (89.2)

470 (86.8)

474 (87.6)

483 (89.3)

Living conditions

Level of corruption

Lack of personal/family safety

Poor future for children

673 (95.7)

675 (96.0)

642 (91.3)

512 (94.7)

511 (94.5)

475 (87.8)

* Percentage of all male respondents

** Percentage of all female respondents

South Africa – Stakeholders

• Characteristics, such as stability, were associated with women making them

preferred recruits – but these same characteristics caused women to seek

more stable employment elsewhere

• Sex and/or gender were also understood as being generators of inequality in

the workplace, but efforts were reportedly being made to ensure equity

Philippines - Literature

• ‘Gendered’ health workforce migration from the Philippines has typically

referred to female nurse migration

• As nursing is a ‘feminized’ profession, there are some significant impacts for

women only on arrival in destination countries

Table 3. Push and pull factors of migration of health workers from the Philippines by sex.

Push and pull factors of migration

Health workers from the Philippines

Male n (%)* Female n (%)**

Easy or very easy to find health job

overseas

13 (19.7) 29 (17.2)

High importance of job satisfaction in a

decision to migrate

49 (72.1) 128 (74.4)

Poor advancement opportunities 15 (22.4) 35 (20.7)

Dissatisfaction with current living

conditions

Lack of employment

High living costs

Poor living conditions

36 (50.0)

24 (32.9)

30 (41.1)

93 (50.8)

59 (32.4)

61 (33.9)

* Percentage of all male respondents

** Percentage of all female respondents

Philippines - Stakeholders

• the goal of bilateral agreements should always be fairness and social justice

to all health workers and professionals, suggesting awareness of problems

with sex/gender

India - Literature

• Female nurses’ intentions to migrate and actual migration is in part

explained by the construction and production of nursing in India:

• female Indian nurses are raised, prepared and educated in a culture that increasingly supports their migration which also discourages the inclusion of men (Rao et al., 2006; Walton-Roberts, 2012). :

Table 4. Push and pull factors of migration of health workers from India (Punjab) by sex.

Dissatisfaction with current…

Health workers from India (Punjab)

Male n (%)* Female n (%)**

Working conditions

Poor income

Poor working conditions

Poor education opportunities

27 (20.1)

22 (16.4)

21 (15.7)

92 (37.1)

32 (12.9)

45 (18.1)

Living conditions

High living costs

Personal safety

Future of your children in India

20 (14.9)

21 (15.7)

57 (42.5)

79 (31.9)

97 (39.1)

103 (41.6)

* Percentage of all male respondents

** Percentage of all female respondents

Table 5. Push and pull factors of migration of health workers from India (Kerala) by sex.

Dissatisfaction with current…

Health workers from India (Kerala)

Male n (%)* Female n (%)**

Working conditions

Poor income

Poor working conditions

Poor education opportunities

190 (76.3)

125 (28.0)

124 (27.8)

378 (42.5)

213 (24.0)

190 (21.3)

Living conditions

High living costs

Personal safety

Future of your children in India

228 (51.0)

76 (17.0)

95 (21.3)

439 (49.3)

128 (14.4)

133 (14.9)

* Percentage of all male respondents

** Percentage of all female respondents

India - Stakeholders

• female nurses stated their intentions to migrate and return to India.

• These intentions may have been based on the types of opportunities (including opportunities for citizenship) that are available in the countries to which they are migrating, and the unemployment and underemployment of nurses in the domestic context acting as push factors

Key Cross-Cutting Themes

• Women migrant health workers “preferred” for “innate” personal

characteristics and cultural reasons

• Female nurse migration - largely influenced and linked to personal

relationships and social networks including friends in the diaspora

• Remittances by female nurses to family back home may play a large role

• Migration may improve social status of women nurses (South Africa, India)

but exposes others to deskilling, sexism and racialization (Philippines, India)

Key Take Aways

• sex/gender mediate health workers’ access and participation in health

education and training, employment, performance and migration and

gendered health worker migration impacts formal and informal sectors.

• These findings suggest that a SGBA is not only useful for revealing gaps in

knowledge, but also offers revisions to dominant approaches to health

worker migration.

Acknowledgements

• Ivy Lynn Bourgeault & Vivien Runnels

• CoPIsL Ron Labonte & Gail Tomblin-Murphy

• Country Teams:

• South Africa: Abel Chikanda3, Jonathan Crush3, Yoswa Dambisya4, Thubelihle Mathole7, David Sanders7

• India: Sreelekha Nair8, Irudaya Rajan8, Atul Sood9, Philomina Thomas10, Margaret Walton Roberts11

• Philippines: Midea M. Kabamalan6, Erlinda Palaganas6, Marian Sanchez6 , Denise Spitzer1

• Jamaica: Annette Elliott Rose2, Joan Guy-Walker5, Adrian MacKenzie2, Rowena Palmer5, Janet Rigby2,

Benjamin Waysome5

• Funding : CIHR Grant # 106493

(1) University of Ottawa, Canada, (2) Dalhousie University, Canada, (3) Balsillie School of International Affairs, Canada, (4) University of Limpopo,

South Africa, (5) Ministry of Health, Jamaica, (6) University of the Philippines, Philippines, (7) University of the Western Cape, South Africa, (8)Centre for Development Studies, India, (9) Jawaharlal Nehru University, India, (10) AIMS, India, (11) Wilfrid Laurier University, Canada