ABSTRACT
Recent decades have seen an increase in cross-border fl ows of health professionals. Of greatest health equity concern are fl ows from poorer countries which have existing and severe shortages of health human resources (HHR) and high burdens of disease to richer countries with shortages (but much less severe) and comparatively lower burdens of disease. Operating simultaneously, “push” and “pull” factors serve to create human capital fl ight or “brain drain” where workers with high levels of training or technical skills emigrate in search of a job and a better life for themselves and their families. While not a new phenomenon, such migration has been accelerated by the past three decades of globalization. The deteriorating economic and broader social and environmental conditions in many so-called “source” countries, for example, are at least partly attributable to liberalization or other forms of global market integration, directly and negatively affecting working conditions, availability of jobs and career development, and thus serving to “push” health workers out of their countries (Marchal & Kegels, 2003). Conditionalities associated with loans or debt relief from the international fi nancial institutions (IFIs) that constrain governments’ abilities to pay adequate salaries or to provide incentives for health workers to remain exacerbate the situation. Globalization also makes it easier for rich countries to “pull” or attract health professionals. Border barriers in high-income countries are being actively lowered for professional, technical, and skilled immigrants, even as they are (frequently) raised for semi-or lesser-skilled individuals. High-income countries, such as the United States (US), Australia, New Zealand, Canada, and, until very recently, the United Kingdom (UK), have come to rely on the immigration of foreign-trained health workers to fi ll their own HHR vacancies. Although there have been attempts to frame the fl ows of health professionals as a continuous “brain circulation” rather than a brain drain, evidence demonstrates that HHR fl ow overwhelmingly and increasingly from poorer to richer countries,
with the poorest countries unable to replace or attract new workers. For these countries, the inevitable result is diminished health care access and services, both critical barriers to improving global health equity. Other factors associated with globalization foster HHR migration, notably the internationalization of professional credentials and, in some instances, notably the European Union (EU), of citizenship. Professional credentials in health as in other fi elds are increasingly recognized across borders, particularly where free trade areas have been formed. Eased migration and mobility (including, for instance, through cheaper, faster, and easier travel, multilingualism, postcolonial ties, and common academic curricula) have contributed to a veritable sense of “global citizenship” worldwide with professional credentials serving as passports. Finally, regional and global trade agreements, key tools of modern globalization, can facilitate international labor mobility.
