Nurse Migration in Asia: Emerging Patterns and Policy Responses 9781032075136, 9781032111117, 9781003218449

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“Nurse migration and mobility is both a personal decision based on individual circumstances, and a complex global policy issue. This book examines the complexities, gives new insights from Asia, and presents important messages for policy makers.” -James Buchan, Adjunct Professor, Faculty Health, University of Technology, Sydney, Australia “A rich analysis of gender, shortage, deskilling, inequality, discrimination and low morale among the migrant nursing workforce in Asian countries with compelling insights into the commercialisation of global health care and the power of agency to influence national and international policy and practice.” -Pam Smith Professor Emerita, University of Edinburgh, UK “Nurse migration is a genuinely global phenomenon whose dynamics play out differently across regional contexts. This edited volume provides welcome new insights into these dynamics in the Asian context - of where, and how, the ‘global’ meets the ‘regional’ and the ‘national’, and rich narratives of the multiple encounters between states and the array of non-state actors involved in ‘producing’, mobilising and relocating nurses across the globe. With pressures set to increase on global nursing workforces worldwide, this book provides a fascinating, timely and remarkable analysis of a major global phenomenon that is here to stay.” -Nicola Yeates, Professor, Social policy, Open University, Milton Keynes, UK

Nurse Migration in Asia

Nurse Migration in Asia explores the ever-increasing need for a larger nursing and healthcare workforce in Asia, where countries are undergoing rapid transformation, given economic globalisation and commercial expansion. The book examines some of the major forces that play key roles in the changing dynamics of 21st century nurse and care worker migration in the Asian context; changes which inevitably have global implications. The country case studies range from India, China, Singapore to Japan and the Philippines. Common themes emerge: the rapid and unpredictable nature of nurse migration patterns, including the direction, purpose and frequency of migration; and the changes in professional training, regulation, and workforce policy. Forces causing these shifts include the changing population demography, global and regional economic fluctuations, and finally changing professional roles and gender dynamics. The book analyses the response to these transformations, and how countries adjust their immigration regulations to attract foreign healthcare professionals. It concludes by highlighting the importance for all countries to remain vigilant as regards the exacerbating workforce crisis, and engage in developing coherent policy governance frameworks to manage healthcare workforce at the national or international levels. A valuable addition to the literature, this book will be of interest to academics in the field of nursing, health and social care workforce studies, population demography, labour markets, gender and international migration studies, globalisation in health and Asian studies. Radha Adhikari is a Lecturer in University of the West of Scotland, UK. Her research focuses on international nurse migration, gender and global health inequality. Her latest research monograph, Migrant Health Professionals and the Global Labour Market: The Dreams and Traps of Nepali Nurses, was published in 2019, by Routledge. Evgeniya Plotnikova is a teaching fellow at the University of Edinburgh, UK. She works for the Master of Public Health (MPH) online programme. Her research interests include health worker migration, bilateral labour agreements, and global governance in health.

Routledge Studies in Asian Diasporas, Migrations and Mobilities

For the full list please refer to URL: https://www.routledge.com/RoutledgeStudies-in-Asian-Diasporas-Migrations-and-Mobilities/book-series/RSADMM Migration, Micro-Business and Tourism in Thailand Highlanders in the City Alexander Trupp Indian Immigrant Women and Work The American Experience Vijaya M. Ramya and Bidisha Biswas Chinese Transnational Migration in the Age of Global Modernity The Case of Oceania Liangni Sally Liu Identity and Experience at the India-Bangladesh Border The Crisis of Belonging Debdatta Chowdhury Asian Women, Identity and Migration Experiences of Transnational Women of Indian Origin/Heritage Nish Belford and Reshmi Lahiri-Roy Virtual Diaspora, Postcolonial Literature and Feminism Ashmita Khasnabish Empowering Subaltern Voices Through Education The Chakma Diaspora in Australia Urmee Chakma Nurse Migration in Asia Emerging patterns and policy responses Edited by Radha Adhikari and Evgeniya Plotnikova

Nurse Migration in Asia Emerging Patterns and Policy Responses

Edited by Radha Adhikari and Evgeniya Plotnikova

Cover image: [add credit line if known or TBC if pending] First published 2023 by Routledge 4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 selection and editorial matter, Radha Adhikari and Evgeniya Plotnikova; individual chapters, the contributors The right of Radha Adhikari and Evgeniya Plotnikova to be identified as the author[/s] of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record has been requested for this book ISBN: 978-1-032-07513-6 (hbk) ISBN: 978-1-032-11111-7 (pbk) ISBN: 978-1-003-21844-9 (ebk) DOI: 10.4324/9781003218449 Typeset in Times New Roman by Taylor & Francis Books

Contents

List of illustrations Preface List of contributors Introduction: Shifting the Focus to Asia

ix xi xiii 1

RADHA ADHIKARI AND EVGENIYA PLOTNIKOVA

1

Nursing Education, Employment, and International Migration: The Case of India

16

YUKO TSUJITA AND HISAYA ODA

2

“Friendly Relations” in Troubled Times: Tracing a Decade of Nurse Migration from India to the UAE

36

MARGARET WALTON-ROBERTS AND BINOD KHADRIA

3

Nursing Shortage and Mobility in China: Current Development and Future Possibilities

53

JUNHONG ZHU, HUAPING LIU AND YINGCHUN ZENG

4

Career Pathways, Long-Term Settlement Policies and Stepwise Migration Aspirations of Philippine-Educated Nurses in Singapore: Lessons for Policymakers

73

MARIA REINARUTH D. CARLOS

5

From Nurses to Care Workers: Deskilling among Filipino Nurses in Japan

95

KATRINA S. NAVALLO

6

Dreams Interrupted: Migrant Filipino Nurses, Gendered Nationalism and Ontological (In)Security during the COVID-19 Pandemic JEAN ENCINAS-FRANCO

115

viii 7

Contents An Ageing Society and a Shrinking Workforce Pool: How Japan is Preparing to Tackle an Impending Demographic Time-Bomb

135

RADHA ADHIKARI AND MARIA REINARUTH D. CARLOS

Conclusion: Nurse Migration in Asia: Current Challenges and Opportunities

155

EVGENIYA PLOTNIKOVA AND RADHA ADHIKARI

Index

166

Illustrations

Figures 2.1 3.1 3.2 3.3 3.4. 4.1

4.2

4.3 4.4 7.1 7.2 7.3

Percentage distribution by locations of nurses from Kerala in 2016 Total number of RN (million) in China Nurses per 1,000 population in China Ratio of nurses to physicians Number of registered nurses per 10,000 population in China by hospital types Number of RNs in Singapore (Singapore citizens and permanent residents – PR); Filipinos and other foreigners (2011–2020) Number of ENs in Singapore (Singapore citizens and permanent residents – PR); Filipinos and other foreigners (2011–2020) Top three destinations of PENs aspiring to migrate and work in another destination Top (first) choice of destinations of PENs aspiring to leave Singapore (choose only one) (% of total per category) People cycling in a busy street in Tokyo Job openings and application ratio in Japan: Employment Referrals for General Workers in Japan Robot in nursing station in a care home in Osaka

37 54 54 55 58

77

78 80 81 141 142 148

Tables 1.1 1.2 1.3 1.4 1.5 1.6 1.7

Number of nursing education institutions in India Background of BSc. in Nursing, from final year students’ survey Nursing students’ intention to work overseas and their preferred destinations Nursing students’ preferred employment options Placement by the type of hospital and college International migration by the type of hospital and college Reasons for international migration by hospital type

18 20 20 22 25 25 26

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List of illustrations

1.8(a) Current workplace by college type: nurses graduated from government school 1.8(b) Current workplace by college type nurses graduated from private school 2.1 MOUs between UAE and India regarding “manpower” and migrant labour issues 3.1 Chinese nursing workforce, 2010 and 2019 3.2 Registered Nurses in China, 2019 4.1 Aspirations of PENs regarding work migration to another country (n=264) 4.2 Result of the logistic regression predicting the likelihood of Philippine-educated nurses (PENs) to aspire to leave Singapore 5.1 Migration pathways for Filipino nurses and non-nurses to enter Japan as care workers

28 28 44 57 57 79 82 102

Preface

The idea for this volume was conceived some years ago, while we were still working towards completing our doctoral dissertations, at the University of Edinburgh. At the time, the concepts of “brain drain” and “ethical recruitment policies from low-income countries to affluent countries” were prominent on the policy agenda. We witnessed the World Health Organization’s Global Code of Practice on the International Recruitment of Health Personnel (2010) being developed, and launched. It was designed to be implemented by source and destination countries involved in the international migration of healthcare workers. The main global nurse and healthcare professionals supplying countries at that time were, and still are, in Asia: namely the Philippines and India. We also learned that the remarkable economic growth taking place in many other countries in Asia, specifically in India, China, and in countries in East Asia, was leading to a major socio-cultural and healthcare policy shifts. Our ideas were stimulated by our realisation of socio-political changes, and emerging policy discussions, and the WHO’s subsequent intervention, through the development of the Code of Practice on the ethical and responsible international recruitment of healthcare professionals. We planned and organised two events in Edinburgh: 1) a workshop to gather information on then the current situation of nurse migration in Asia and migrant nurses’ real-life experience in the UK (in 2011); and 2) based on the workshop, we organised a two-day conference on “Asian nurse migration” in 2013, inviting international scholars working in this field. The 2013 conference gave us the impetus to further develop our understanding, and prepare a volume that provides a comprehensive picture of the healthcare workforce labour market situation in an Asian context. However, for a number of very valid reasons, the project has progressed slowly, indeed much more slowly than we had anticipated. Nevertheless, the production of this volume is in fact extremely timely, given the current situation as regards the management of health workers globally. For the world has been faced with critical shortages of this workforce, and with management challenges at unprecedented scales, posed by the Covid-19 pandemic. Obviously, since the 2013 Edinburgh conference, changes have taken place in the nurse and care work labour market in Asia and globally. Some of the contributors to this

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Preface

volume were conference participants, and now, almost a decade later, bring their very welcome updated and contemporary knowledge of their fields to the discussions. We are very grateful to all the participants, for all they brought to the conference through their sharing of some extremely valuable information. This event was financially supported by the Confucius Institute, Edinburgh, and through a small grant from the University of Edinburgh. We thank these institutions for their support. We were professionally supported by a number of our senior colleagues in the University in making this conference a success, we are very grateful to them all. Conceived almost a decade ago, and evolving and developing slowly, this volume offers a broad range of perspectives, capturing lived experiences and opinions through multi-disciplinary lenses. The contributors come from diverse professional backgrounds, and bring in their valuable expertise: in international migration; the economics of international labour migration; health workforce management and policy; politics; social policy and more, highlighting the nature and the scope of international nurse migration. While the contributors’ individual styles of argument and discussion are very diverse, the one common theme that, very importantly, has been identified by all contributors, is the apparent lack of coherent policy in making migration safe and orderly, and in valuing the contributions made, both at home and abroad, by nurses and care workers, the vast majority of whom are women. Bringing all these different perspectives together and presenting them in a simple framework has been a challenging task. However, contributors have given their precious time, shared their perspectives, focusing on the common theme, and invested their energy to shape this volume. We are extremely grateful to all contributors for their enthusiasm and timely support in the completion of this project. Finally, we are grateful to Kate Weir for proofreading the manuscript and helping us make this volume clear and readable. We offer our thanks for all the guidance and support we have received from Dorothea Schaefter and Saraswathy Narayan (Routledge Editorial Team) in the past year, as it has indeed been praiseworthy. Radha Adhikari and Evgeniya Plotnikova, Edinburgh, Scotland, October 2022

Contributors

Radha Adhikari is a Lecturer in University of the West of Scotland. Her research focuses on international nurse migration, gender and global health inequality. Her latest research monograph, Migrant Health Professionals and the Global Labour Market: The Dreams and Traps of Nepali Nurses, was published in 2019, by Routledge. Maria Reinaruth D. Carlos is currently Professor of Economics at the Graduate School and Faculty of International Studies in Ryukoku University, Kyoto, Japan. She conducts research on Filipino migration, particularly the stepwise migration of Filipino nurses and careworkers, and Filipino residents in Japan. Jean Encinas-Franco, PhD is an Associate Professor at the Department of Political Science, University of the Philippines in Diliman. She teaches Feminist International Relations, Gender and Politics, and Qualitative Methods. Her research interests deal with gender and the politics of international migration from the Philippines. Binod Kharida is an author, editor and former professor of Jawaharlal Nehru University (JNU), New Delhi, His first book, The Migration of Knowledge Workers (1999) brought a paradigm shift in the discourses on brain drain. He is co-editor of World Migration Report 2020 (IOM-UN Migration). Huaping Liu is Professor and Former Dean in School of Nursing, Peking Union Medical College. Her research focuses on nursing management and nursing education. She is an advisor for national health policies reform in China, and the chief editor of the International Journal of Nursing Sciences. Katrina S. Navallo is currently an Adjunct Professor at the Asian Center, University of the Philippines Diliman. She obtained her Doctor in Area Studies in Kyoto University, where she did an ethnography of Filipino longterm care workers in Japanese care facilities, focusing on their embodied caregiving experiences and relations with the elderly residents. Prior to pursuing graduate studies, she has worked on issues of labour migration and free labour mobility in ASEAN as a consultant for the Asian Development Bank.

xiv List of contributors Hisaya Oda is a Professor of the College of Policy Science, Ritsumeikan University, Japan. His work on migration has been published in various journals such as Asian Population Studies, and Journal of International Migration and Integration. Evgeniya Plotnikova is a teaching fellow at the University of Edinburgh. She works for the Master of Public Health (MPH) online programme. Her research interests include health worker migration, bilateral labour agreements, and global governance in health. Yuko Tsujita is Senior Research Fellow, Institute of Developing Economies (IDE-JETRO), Japan. Her recent research interests include migration, labour and education. She is the co-editor of Human Resources for the Health and Long-Term Care of Older Persons in Asia (ERIA). Her work focuses mainly on South Asia. Margaret Walton-Roberts is a professor in the Geography and Environmental studies department at Wilfrid Laurier University, and affiliated to the Balsillie School of International Affairs, Waterloo Ontario. Her latest edited collection, Global Migration, Gender and Health Professional Credentials: Transnational Value Transfers and Losses, was published by the University of Toronto Press in 2022. Yingchun Zeng is a Postdoctoral Fellow in The Hong Kong Polytechnic University. Supported by seven funded research projects, more than 60 publications in international peer-reviewed journals, owns two patents and two software Copyright. She has developed national and international research collaborations in cancer research. Junhong Zhu is Associate Professor in Nursing Studies of Medical School in Zhejiang University. She is a registered nurse with 30 years’ work experience in China. She has a PhD in Nursing from Edinburgh University in 2012. Her research interests include nursing workforce issues, safety and quality of health care.

Introduction Shifting the focus to Asia Radha Adhikari and Evgeniya Plotnikova

In the last few decades, in pre-Covid-19 contexts, policy makers and workforce managers have yet again had to face acute, indeed chronic, shortages of nursing and healthcare professionals. Scholars stress a shortfall of about 1.13 million healthcare workers in India alone to meet the target of 22.8 healthcare professionals per 10,000 population in the country (Karan et al. 2021, p.6). The health workforce shortage is acutely experienced by most countries in the world today (WHO 2020). The Covid-19 pandemic has further amplified the already fragile workforce situation, pushing countries’ health systems to a tipping point (Buchan and Catton 2020). Currently, most countries are struggling to find ways to deal with their acute nursing and care workforce crises, as well as find sustainable solutions to their management challenges. Issues such as international recruitment, and the migration of healthcare professionals, have affected most countries globally, and at an unprecedented scale. The healthcare labour market in recent years is changing rapidly and creating more job opportunities globally. Pre-existing nursing and healthcare worker shortages and international recruitment of this workforce have generated many policy discussions and have received a lot of attention from wider stakeholders: health system managers, workforce planners and policy makers, scholars in gender and migration studies, social scientists, economists, and national and international media. With its specific focus on the Asian context, this volume offers multi-disciplinary perspectives on a health and social care labour market, looking at nurse education and workforce management, professional regulation, international recruitment opportunities and practices, and retention policy strategies for this workforce in several Asian countries and beyond. The discourse on the international recruitment and migration of health professionals has centred on the concomitant issue of a “brain drain”, within the context of global health inequality. The international migration of health professionals has been described as exacerbating the unequal distribution of human resources for health, mainly in those low-income countries with already fragile healthcare systems. Affluent countries have been criticised for draining much-needed human resources from resource-poor countries in Asia, sub-Saharan Africa and the Caribbean (Atte 2021; Kingma 2006). DOI: 10.4324/9781003218449-1

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Further, nurse migration has also been discussed from a gendered-migration perspective as a “care drain”, resulting from the feminisation of migration (Sassen 2006; DiCicco-Bloom 2004; Ehrenreich and Russell-Hochschild 2002; George 2000). It has been argued that foreign nurses and care workers, the vast majority of whom are women, are being treated as commodities in the global nursing care chains (GNCCs), mainly benefiting affluent migrantreceiving societies. Furthermore, some source countries are promoting the “export” of nurses and care workers using it as a response to economic development challenges at the expense of national health and care systems (Yeates 2009). From a human rights perspective, it has been argued that it is an individual’s right to look for better life opportunities in the liberal global healthcare labour market. It should be balanced, however with the “right to health” in source countries affected by the active international recruitment of health personnel (Runnels, Packer and Labonté 2016; Plotnikova 2011). Other important foci of debate include immigration policies and national security (Dimaya et al. 2012; Elbe 2011); social integration and migrants’ rights; and finally, identity, citizenship, and social protection of migrant workers (Choi and Lyons 2012; Ho 2008; Winklemann‐Gleed 2006). It has been recognised that previous research on international nurse migration has considered cross-border movements, primarily from low- or middle-income countries to high-income countries (Yeates and Pillinger 2018). Furthermore, such research has focused on the destination countries’ perspectives, looking at the “who”, “why”, and “how” questions: who migrates and why; and how to manage the internationally recruited workforce, including the issues of migrants’ social and professional integration (Connell 2008). Further to this, in the recent past, the primary focus has been on finding “ethical” and “sustainable” solutions for filling a workforce gap in affluent countries, namely the USA, Canada, Australia, New Zealand, the UK, and other countries in Europe. This interest in ethical recruitment practices has resulted in the development and introduction of the WHO Global Code of Practice on the International Recruitment of Health Personnel in 2010 (Bourgeault et al. 2016). Alongside the argument of ethical recruitment, there are more complex and varied migration patterns, and flows of cross-border mobilities are emerging with new “source” and “destination” countries – an issue which demands closer examination within and amongst the global regions. For instance, “medical tourism” has been one of these rapidly developing phenomena, with some of the main ‘hubs’ emerging in Asia, namely in Singapore, Thailand, and India. As a result, these countries have become attractive destinations, not only to overseas patients but also to international nurses and health professionals (Oda et al. 2018). China’s ambitious “Belt and Road Initiative” has a huge potential to make major impacts on the global economy (Macaes 2019). Scholars project that it will reconfigure the current political and economic power, which will have a

Introduction

3

major impact on health, including on the education and international migration of health professionals (Chow-Bing 2020; Macaes 2019; Hu et al. 2017). An emerging pattern of intra-regional migration of health professionals could be illustrated with the example of the Gulf Cooperation Council (GCC) countries recruiting healthcare professionals from a number of countries in Asia and beyond (Sheikh et al. 2019; Percot 2006). Another emerging and rapidly developing phenomenon is the negotiation of bilateral labour agreements between source and destination countries in Asia (Yeates and Pillinger 2019). Such agreements are negotiated as part of the broader cooperation frameworks covering strategic partnerships in several areas, including trade and security. For instance, Japan has been recruiting foreign nurses, primarily from Indonesia, the Philippines, and Vietnam, under Economic Partnership Agreements (EPAs) with these countries (Hirano et al. 2020; Carlos 2012). Furthermore, although an increasing number of countries in Asia are now preparing healthcare professionals for the global market, many of them experience health workforce shortages at home. In response to growing regional, as well as global, demands for health workers and nurses, in particular, some countries in Asia, including India, China, and most recently Indonesia and Nepal, undertake strategic decisions to educate more nurses and facilitate their migration and employment overseas. For this, some source countries have adapted their curricula to match the needs of destination countries (Adhikari 2019; Matsuno 2009). For instance, in the Philippines, the focus has shifted from training community nurses to training clinical specialist nurses. Subsequently, this has led to a mismatch between available healthcare skills and the health needs of the Philippine population (Marcus et al. 2014; Dimaya et al. 2012). This phenomenon of governments in source countries looking out for international opportunities for nurses and supporting migration is not new. Such a pattern has been followed by the Philippines for several decades (Thompson and WaltonRoberts 2019), but in recent years, this has been rapidly adopted by other health professional-supplying countries in Asia. Paradoxically, countries educating health personnel for “export” often experience domestic shortages, especially in remote and rural areas. Scholars have also drawn attention to existing gaps in the health workforce in many source countries in Asia, including the Philippines, India, Nepal, and China (Adhikari 2019; Tangcharoensathien, et al. 2018; Yeates and Pillinger 2018; Garner et al. 2015; Zhu 2012; Connell, 2010; Matsuno 2009). These studies have articulated the need to develop comprehensive policies on the training and retention of healthcare professionals in order to address workforce challenges at national and regional levels. Another dimension, which has been noted in the literature, which requires further research, is an interdependence of migration patterns and national health workforce policies, including professional education and licensing regulations. In response to fluctuations in national, regional, and global demand, some source countries in Asia have introduced various changes in professional

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education and regulation (Marcus et al. 2014; Dimaya et al. 2012; Zhu 2012). This phenomenon is extensively discussed in this volume and illustrated in the individual countries’ case studies. Professional nursing and the healthcare labour markets in most Asian countries are currently being transformed at an unprecedented scale and speed. However, literature on the international migration of healthcare professionals generally represents a Euro-American perspective. Apart from some source country-specific studies and regional overviews, health professional migration in the Asian regional context has not been comprehensively explored (Tangcharoensathien et al. 2018; Yeates and Pillinger 2018; Garner et al. 2015; Connell 2010; Matsuno 2009). As migration patterns are becoming more complex, there is a need to update, chronicle, research, and understand how this is evolving and growing in Asia, with relation to changes in healthcare workforce planning and management policies, including nursing education and professional regulation. In its presentation of various countries’ case studies, this volume details and illustrates the labour market interdependences and integration, including exploring nurse and care worker migration patterns in the world’s largest and most populous continent – Asia. We bring Asian perspectives to the forefront of the discussion in this volume for three key reasons. Firstly, the issue of changing population demography and emerging global health challenges has had a major impact on countries in Asia. Secondly, changing gender roles and family dynamics have, as in the West, led to an increasing number of Asian women entering the labour market and taking up paid work, in addition to their everyday domestic care responsibilities in many instances. Finally, there is the issue of the expanding healthcare labour market and privatisation in healthcare. With Asian economic growth, the private healthcare sector is expanding rapidly, creating a demand for bigger workforce, but there are national shortages of health professionals, including those of nurses and care workers.

Changing population demography and emerging public health challenges in Asia Asia has the highest proportion of the world’s population, estimated at over 60% (UN 2019). The most populous countries are China, India, Bangladesh, Pakistan, Indonesia, and Japan. An ageing population and declining birth rate, leading to a shrinking workforce pool, is of great concern in this continent, and there is a pressing need for more healthcare professionals. The situation is compounded by what is a global rise in non-communicable diseases (NCD) and long-term health conditions. As reported by the NCD Alliance (2017), the global burden of NCDs will continue to increase during the next decade, with the highest absolute number of deaths expected in the Western Pacific and SouthEast Asia regions. The subsequent increasing burden on already fragile and expanding health systems with healthcare workforce shortages has already been acutely felt in many countries in Asia (Liu et al. 2016).

Introduction

5

Various factors influence changes in population demography. Some of the main ones are increasing life expectancy, declining fertility (and birth rates), urbanisation, and migration. Advances in medicine and healthcare technology, general improvements in living standards and public health services have changed life expectancies, and people across the world are now living increasingly longer. Japan has the highest proportion of elderly people and has been seen as the “super ageing society”, with a notably declining birth rate (McCurry 2015; Muramatsu and Akiyama 2011). China faces similar challenges because of its previous “one child” policy, leading to the current “4–2–1 phenomenon”, namely four grandparents, two parents and one young adult (Green 2014; Zhu 2012). Given that Asia has the highest proportion of the world’s population, including the elderly, the availability and provision of care for the elderly is an issue requiring urgent action. As a result of declining birth rates, most Asian countries are currently experiencing labour shortages as regards being able to provide care for their elderly citizens. There are other sources of concern related to the changes in population demography and the shrinking workforce pool in Asia. There is a significant percentage of outmigration of young people from rural villages to urban centres and of labour migration to international destinations, causing labour shortages in rural areas (Sharma 2018; Henley 2017). The shrinking workforce pool in all sectors of society, including rural agriculture and manufacturing, is increasingly pronounced. Rapid urbanisation has created a different set of public health challenges, as the existing infrastructure becomes overburdened by population growth, with a huge concomitant impact on healthcare services. Additionally, most countries carry the increased burden of long-term health conditions. Cardiovascular conditions, diabetes, and mental health problems demand an increased care workforce for their long-term management. Due to the increased disease burden, many health systems in Asia, and globally, are already experiencing a “care crisis” or “care workforce crisis” (Campbell 2013).

Changing gender roles and family dynamics Nursing and care work have always been a highly gendered profession. Almost 90% of nurses globally are women, and so international nurse and care worker migration is a gendered migration phenomenon. In particular, since the Asian economic boom of the late-1980s, women in most countries in this region have begun to enter local, national, and increasingly global labour markets, resulting in there being less time for them to look after their children and their elderly or sick family members at home (Michel and Peng 2017; Lan 2006). Female migration in Asia, to work as nurses, care workers, and housemaids abroad, is a growing phenomenon, creating a “care deficit” at home. Care work, once termed as women’s work, has become increasingly institutionalised. As care at home is no longer the main option, care provision

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falls to the health system, compounding pre-existing staffing shortfalls in institutional settings (Michel and Peng 2017). Additionally, socio-cultural, economic, and political factors all play crucial roles in women entering paid work and nurse migration. For example, some societies and state policies, such as in the Philippines, India, Nepal, and China in recent years, actively promote and encourage nurse migration. This evidently has a huge impact on traditional caregiving practices in families and communities, leading to an increased role for the healthcare system. It is the case that even those women still living in their local communities are engaged in serving global clients. In India, most garment factory workers, carpet weaving industry workers, and international call centre workers are women. This is the case too in manufacturing industries in China, Vietnam, and Bangladesh, the Philippines, amongst others (ADB 2016). Wherever they are, they contribute to the global economy, providing services for global clients. For them, there is less time, or no time, to look after elderly and frail family members. With a rapidly changing healthcare labour market and changing women’s role in society, how to provide care to an increasing number of the ageing population is a major concern in Asian countries.

Market expansion and privatisation in healthcare in Asian countries With economic globalisation and commercial expansion, recent decades have seen global power relationships shifting from Europe and North America to Asia. India and China have become Asia’s “emerging superpowers” or “emerging economies”, and are enjoying a phenomenal growth in public sector spending, as well as many other neighbouring countries, such as Thailand, Malaysia, South Korea, and Singapore. Improvements in national and regional economies have contributed to a rapid expansion in the commercial production of healthcare technologies and services. These production and service industries are booming and thriving. People’s purchasing power has increased, and the consumption of healthcare products and services has significantly increased in Asia (WHO 2019). Many Asian countries are currently exploring and promoting medical tourism as a potential economic opportunity (Connell 2010). Thailand’s ambition of becoming the “Asian medical hub” is one such example (Wongboonsin et al. 2018). International companies establish hospitals and clinics, and people travel internationally within Asia for medical treatment and other health and beauty services. Private hospitals in Thailand, Singapore and India offering cosmetic surgery to wealthy global clients are some examples of the expansion of the healthcare service in Asia (Noree et al. 2016). This rapidly growing healthcare market demands a larger workforce of nurses, doctors, and other health professionals. Additionally, there are joint ventures in health professional education and health service provision, including trade in social services. Currently, Singapore, Japan, Thailand, the Maldives, and countries in the Gulf have become

Introduction

7

prominent foreign nurse and care worker-receiving countries. The countryspecific case studies presented in this book, of India (Chapters 1 and 2), Japan (Chapters 5 and 7), the Philippines, Singapore (Chapters 4, 5 and 6), and China (Chapter 3), all illustrate the transnational and interconnected process of professional education, regulation, and the healthcare labour market situation in the region. In response to labour market expansion in the region and to make use of international resources, countries in Asia are adjusting their immigration and border control regulations. Not only is nursing and medical education offered to international candidates, but foreign workers are also invited to fill vacancies in the wider health and care sectors. Countries in the Gulf, Japan and Singapore, are prime examples of this. Chapter 2 discusses this in more detail, with reference to the migration of Indian nurses to the United Arab Emirates (UAE), and Chapters 5 and 7 focus on Japan’s Economic Partnership Agreement (EPA) with its Asian neighbours. International recruitment and migration further exacerbate existing global inequalities in health. To deal with emerging public health challenges (such as the rise in NCD), the UN, alongside most countries in the world, is currently aiming towards achieving Universal Health Coverage (UHC) by 2030. This requires adequate and sustainable staffing at all levels in a country’s health system (Campbell 2013). With empirical evidence, this volume illustrates how government and other stakeholders can take proactive approaches to current and future nursing workforce planning and preparation and, importantly, develop adequate and sustainable workforce management strategies. Furthermore, it adds muchneeded new insights into changing health system contexts, and to nurse migration in Asia, in particular, it enhances our understanding of the dynamics at play there, where many countries have significant health workforce shortages. We argue that it is important to look at the nurse-supplying countries and the nurse-receiving countries simultaneously in order to understand the changing regional labour market dynamics. As we are living in an increasingly interconnected world, any change in the Asian context, ultimately has global consequences. Therefore, in order for local, national and regional efforts to be effective, we have a pressing need to develop clear strategies for national, regional and global health governance. Chapters in this book examine cases of country-specific nursing and care workforce issues, namely their education, regulation, recruitment, workforce management and migration policies, and discuss their wider global implications. The narratives presented in this volume demonstrate how national health workforce policies, including education and professional regulation, depend on and reflect the changes in the regional and global labour markets. This volume invites the reader to consider migration, professional education, and regulation as interconnected policy areas, which are significantly shaped by the global labour market forces, global actors, and migration governance

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Radha Adhikari and Evgeniya Plotnikova

regimes. In this, we argue that the analysis and understanding of the interconnectedness between the recent (and current) national trends, and changes in training, employment, and migration of the health workforce in the global context, are both critical in developing adequate policy responses at national levels and effective global migration governance frameworks. Thus, taking into account these emerging trends, this volume attempts to identify and examine the new patterns and changes in nurse education, employment, and cross-border mobilities in the Asian context and supports the development of adequate policy responses to the issues around health worker migration at national and international levels.

Chapter Overview Chapter 1 Nursing education, employment, and international migration: the case of India (Tsujita and Oda) By presenting empirical findings from two studies conducted in the Southern Indian states of Kerala and Tamil Nadu, this chapter challenges the prevailing stereotypical discourse of international nurse migration as an irreversible type of “brain drain” of nurses from low-income countries to affluent ones. Discussion in this chapter suggests that a significant number of Indian nurse graduates want to obtain government positions in the country, considering this a better career option than an international move. Even after spending a period working abroad, Indian nurses want to return, preferably to government positions. This indicates that the Indian government can still tap into this valuable human resource for healthcare. Study findings like these can offer valuable understanding for future workforce planning in India and internationally. Chapter 2 “Friendly relations” in troubled times: Tracing a decade of nurse migration from India to the UAE (Walton-Roberts and Khadria) Labour migration to the Gulf States from countries in Asia has been an ongoing issue for decades, and health professionals, including nurses, have been part of a bigger migration picture. Studies have highlighted this phenomenon, and a significant proportion of Indian nurses and healthcare professionals work in the Gulf States. Some use their posts in the Gulf States as a stepping-stone to further destinations (Percot 2006). As yet, no specific policy plan is in place between India and UAE, to manage nurse and health professional migration. However, in recent decades, there have been several bilateral agreements on labour migration between India and UAE, and other countries in the Gulf. This chapter examines some of these agreements on labour migration and highlights the need to have a specific pathway for health workers’ migration that is mutually beneficial to all parties involved: both the sending and receiving governments, migrant nurses, and the healthcare system.

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Chapter 3 Nursing shortage and mobility in China: current development and future possibilities (Zhu, Liu and Zeng) This chapter provides an overview of the Chinese professional nursing situation, both in terms of nursing education and workforce management. This case study clearly suggests that international nurse migration is also a result of poor workforce management at home. Frustrated and disappointed nurses in China have considered leaving the profession, and the country, in search of “greener pastures” abroad. Discussion in this chapter highlights the importance of nurses’ professional autonomy, not only to improve nursing workforce retention, but also to keep practising and experienced nurses active in influencing health policy. In addition, the chapter briefly, but clearly, highlights many complex issues, from China’s nursing workforce preparation, their working conditions and choice of employment contexts, to its ambitious future economic and political plans of Belt and Road Initiative (BRI). The Chinese government’s economic strategies extend beyond BRI, and BRICS (Brazil, Russia, India, China and South Africa) co-operation. It seeks to have global influence, both politically and economically. Finally, China’s response to the Covid-19 pandemic in the country has been impressive, in addition to extending “a helping hand” to Serbia, Italy, and other countries. Nevertheless, many issues still remain to be uncovered, and merit further exploration and research. Chapter 4 Career pathways, long-term settlement policies and stepwise migration aspirations of Philippine-educated nurses (PENs) in Singapore Lessons for policymakers (Carlos) In recent years, in the Philippines, the availability of nurse education has decreased and, consequently, the total number of licensed nurses has been shrinking. Given its position as one of the main global nurse-supplying countries, changes in the Philippines will have major global consequences. The discussion in this chapter suggests that demand for PENs in the West has been fluctuating in the past few decades, but it has remained steady in the Gulf States. It is mainly due to a lack of job opportunities in their own country that so many PENs migrate internationally, with some even considering non-nursing jobs in Singapore and Thailand. In recent decades, Singapore has become a nurse recruitment hub for western recruiters and a stepping-stone for PENs. Due to poor migrant workforce management in Singapore, Filipino nurses look for other more prudent destinations, preferably in the West. This idea of stepwise migration means that migrant nurses are constantly looking out for choices for their new destination countries that would provide better employment opportunities and social lives. Recruitment of PENs is a widely discussed issue, and retention of this workforce has been a major challenge for most international recruiters. Successful retention of any workforce, be it local, national, or international,

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Radha Adhikari and Evgeniya Plotnikova

requires major policy attention, from provision for appropriate visas or work permits to investment in social integration, professional development, and appropriate career pathways. Focusing primarily on what makes Filipino nurses stay in Singapore, the discussion in this chapter highlights a key message for the successful workforce retention of foreign-educated nurses, which is to value and recognise their professional qualifications and create clear career progression pathways. This appears to be a strong determinant for PENs to remain in post in Singapore. Chapter 5 From Nurses to Care Workers: Deskilling among Filipino Nurses in Japan (Navallo) This chapter examines the migration context and patterns of Philippine-educated nurses (PENs) and care workers in Japan. There are approximately 2,500 PENs and care workers in Japan who came via the Japan–Philippines Economic Partnership Agreement (EPA) from 2009 to 2019. Out of this number, 588 entered as nurses, and 2,004 entered as care workers (Navallo 2020). The stringent barriers for nurse migration reflect the lower number of nurses considering nursing pathways to enter Japan compared to care workers and are evidence of the fact that many nurses have taken up care worker positions. Based on the analysis of indepth interviews with 32 Filipino nurses who became care workers in Japan, this chapter interrogates the experience of deskilling among PENs who have entered Japan as care workers in long-term care facilities for the elderly. Despite the strong possibility of deskilling, nurse migrants who take up care work intentionally configure their nursing skills and training to create opportunities that allow them to migrate. However, Japan’s migration policy limits them to the care work sector, thus significantly altering their career progression and their prospects of returning to the nursing profession. Discussion in this chapter illustrates how care regimes, migration and employment policies in sending and receiving states shape the migration trajectories for qualified nurses. It finds that state-controlled migration structures in the Philippines actively exercise selective preference in deciding who can migrate to Japan, while those who are unable to do so resort to individual migration tactics, considering alternative options, such as applying for jobs below their educational attainments and skill levels, to pass through the stringent institutional migration barriers. Chapter 6 Dreams interrupted: Migrant Filipino nurses, gendered nationalism and ontological (in)security during the Covid-19 pandemic (Encinas-Franco) Discussion in this chapter highlights nurse employment issues in the Philippines during the Covid-19 pandemic. It raises a number of critical concerns around the Filipino government’s labour emigration policy and its paternalistic nurse migration management practices such as the cap on nurse outmigration during the Covid-19 crisis.

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Chapter 7 An ageing society and a shrinking workforce pool: How Japan is preparing to tackle an impending demographic time-bomb (Adhikari and Carlos) This chapter highlights how Japan is exploring and preparing for the sustainable management and supply of their future health and social care workforce and examines current strategies in workforce management, particularly in the longterm and elderly care sector. In 2000, the government of Japan took a radical step: streamlining funding for the elderly and long-term care and making provision for regulated professional cadres, Certified Care Workers (CCW) and independent care workers to provide long-term care. Due to the domestic shortage of care workforce, the Government decided to recruit this workforce from international sources. International recruitment of the care workforce has continued since then. Overall, the government’s efforts to prepare adequate numbers of care workers, particularly CCWs and in their long-term care funding scheme, with the commitment of the care home sector and the development of technology to assist long-term care, have become the major pillars in elderly care provision in Japan. Conclusion: Nurse migration in Asia: Current challenges and opportunities (Plotnikova and Adhikari) This concluding chapter offers an overview of the rapidly evolving scenarios of nursing and care workforce management, with issues and challenges at home and emerging patterns of international recruitment and migration of this workforce, before and during the Covid-19 pandemic in the Asian context. Country case studies have revealed the involvement of various actors with vested interests in the international recruitment and migration of nurses and care workers. Multiple workforce management challenges have been identified in different country contexts, including training, recruitment, retention, and migration of healthcare personnel. In response to these challenges, most countries have taken a patchwork approach, lacking a coherent strategy. Therefore, the concluding chapter highlights that countries need to have a suitable health workforce plan and sustainable workforce management strategies in place. All governments should consider potential global health workforce challenges while addressing local and national issues. Furthermore, countries should work collaboratively to develop and implement a coherent migration governance policy strategy urgently, as workforce shortages in one country (or region) can have global implications.

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imaginations in a post modern world, pp. 144–174. Berkeley: University of California Press. Green, D. (2014) ‘Elderly care – coping with the 4:2:1 problem’, China Outlook, online news. Available at: http://chinaoutlook.com/elderly-care-coping-with-the-421-problem/ (Accessed 18 August 2020). Henley, G. (2017) Supporting economic transformation: Pathways to prosperity and inclusive job creation in Nepal, background paper: agroprocessing sector, Overseas Development Institute, available online at: https://set.odi.org/wp-content/uploads/ 2017/10/3.-SET-Nepal-Agro-processing-for-ET_Oct-2017.pdf (Accessed 16 September 2020). Hirano, Y.O., Tsubota, K. and Ohno, S. (2020) ‘Factors associated with the recruitment of foreign nurses in Japan: A nationwide study of hospitals’, Human Resources for Health, 18 (1), p. 88. doi:10.1186/s12960-020-00532-5. Ho, C. (2008) ‘Chinese nurses in Australia: Migration, work, and identity’, in J. Connell (ed.) The international migration of health workers. New York; London: Routledge, pp. 147–163. Hu, R., Liu, R. and Hu, N. (2017) China’s Belt and Road Initiative from a global health perspective, The Lancet Global Health, 5 (8), pp. e752–e753. doi:10.1016/ S2214-109X(17)30250-4. Karan, A., Negandhi, H., Hussain, S., Zapata, T., Mairembam, D., De Graeve, H., Buchan, J. and Zodpey, S. (2021) ‘Size, composition and distribution of health workforce in India: Why, and where to invest?’, Human Resources for Health, 19 (39). Available at: https://human-resources-health.biomedcentral.com/articles/10. 1186/s12960-021-00575-2 (Accessed 5 June 2021). Kingma, M. (2006) Nurses on the move: Migration and global health care economy. Ithaca and London: ILR press, an imprint of Cornell University Press. Lan, P.C. (2006) Global cinderellas: Migrant domestics and newly rich employers in Taiwan, Duke University Press. Liu, J.X., Goryakin, Y., Maeda, A., Bruckner, T and Scheffler, R. (2016) Global health workforce labor market projections for 2030. The World Bank (Policy Research Working Papers). doi:10.1596/1813-9450-7790. Available at: https://elibrary.worldba nk.org/doi/abs/10.1596/1813-9450-7790 (Accessed 22 February 2022). Macaes, B. (2019) Belt and Road: Chinese world order, Penguin, Random House India. Mackintosh, M., Raghuram, P. and Henry, L. (2006) ‘A perverse subsidy: African trained nurses and doctors in the NHS’, Soundings, 34 (34), pp. 103–113. Marcus, K., Quimson, G., and Short, S.D. (2014) ‘Source country perceptions, experiences, and recommendations regarding health workforce migration: A case study from the Philippines’, Human Resources for Health, 12, pp. 1–10. Matsuno, A. (2009) Nurse migration: The Asian perspective. ILO/EU Asian Programme on the Governance of Labour Migration, technical note. Available at: http://pstalker. com/ilo/resources/Technical%20Note%20-%20Nurse%20Migration%20by%20A% 20Matsuno.doc (Accessed 20 September 2009). McCurry, J. (2015) ‘Japan will be model for future super-ageing societies’, The Lancet, 368 (1003), p. 1523. Michel, S. and Peng, I. (2017) Gender, migration, and the work of care: A multi-scalar approach to the Pacific Rim. Cham: Springer International Publishing, doi:10.1007/ 978-3-319-55086-2_1. Muramatsu, N. and Akiyama, H. (2011) Japan: Super-ageing society, preparing for the future, The Gerontologist, 51 (4), pp. 425–432.

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Navallo, K. (2020) Paid to care: The ethnography of body, empathy and reciprocity in care work among Filipinos in Japan. Unpublished dissertation. Kyoto University, Japan. Noree, T., Hanedeld, J. and Smith, R. (2016) ‘Medical tourism in Thailand: A crosssectional study’, Bulletin of the World Health Organization, 94, pp. 30–36. doi: http://dx.doi.org/10.2471/BLT.14.152165. NCD Alliance (2017) The Global Epidemic. Available at: https://ncdalliance.org/ the-global-epidemic#:~:text=Home%20%2F%20NCD%20Facts%20%2F%20The% 20Global%20Epidemic&text=Worldwide%2C%20NCDs%20account%20for%2060, cause%20of%20disability%20by%202030 (Accessed 8 January 2023). Oda H., Tsujita, Y. and Rajan, S.I. (2018) ‘An analysis of factors influencing the international migration of Indian nurses’, International Migration and Integration, 19, pp. 607–624. Percot, M. (2006) ‘Indian nurses in the Gulf: Two generations of female migration’, South Asia Research, 26 (1), pp. 41–62. Plotnikova, E. (2011) ‘Cross-border mobility of health professionals: Contesting patients’ right to health’, Social Science and Medicine, 74, pp. 20–27. Runnels, V., Packer, C. and Labonté, R. (2016) ‘International health worker migration: Issues of ethics, human rights and health equity’, Handbook of Migration and Health [Preprint]. Available at: https://www.elgaronline.com/view/edcoll/9781784714772/ 9781784714772.00017.xml (Accessed 11 September 2020). Sassen, S. (2006) ‘Global cities and survival circuits’, in M. Zimmerman, et al. (eds). Global dimensions of gender and carework. Stanford University Press, pp. 32–38. Sharma, J.R (2018) Crossing the border to India: Youth, migration and masculinities in Nepal, Temple University Press. Sheikh, J.I., Cheema, S., Chaabna, K., Lowenfels, A.B., and Mamtani, R. (2019) ‘Capacity building in the health care professions within the Gulf cooperation council countries: Paving the way forward’, BMC Medical Education, 19 (83). Tangcharoensathien, V., Travis, P., Tancarino, A.S., Sawaengdee, K., Chhoedon, Y., Hassan, F. and Pudpong, N. (2018) ‘Managing in- and out-migration of health workforce in selected countries in South East Asia region’, International Journal of Health Policy and Management, 7 (2), pp. 137–143. doi:10.15171/ijhpm.2017.49. The Hindu (2019) ‘State to provide trained nurses for the Netherlands’. Available at: https://www.thehindu.com/news/national/kerala/state-to-provide-trained-nursesfor-the-netherlands/article28774068.ece (Accessed 15 February 2022). Thompson, M. and Walton-Roberts, M. (2019) ‘International nurse migration from India and the Philippines: The challenge of meeting the sustainable development goals in training, orderly migration and healthcare worker retention’, Journal of Ethnic and Migration Studies, 45 (14), pp. 2583–2599. UN – United Nations (2019) ‘World population prospects: The 2019 revision’, United Nations, Department of Economic and Social Affairs. Available at: https://population. un.org/wpp/Download/Standard/Population/ (Accessed 27 January 2022). Winklemann‐Gleed, A. (2006) Migrant nurses: Motivation, integration and contribution. Oxon: Radcliffe Publications. WHO – World Health Organization (2020) State of the world’s nursing 2020. Geneva: World Health Organization. WHO – World Health Organization (2019) ‘Global spending on health: A world in transition’. WHO/HIS/HGF/HFWorkingPaper/19.4. Geneva: World Health Organization.

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Available at: https://www.who.int/publications/i/item/WHO-HIS-HGF-HFWorkingPap er-19.4 (Accessed 4 November 2022). Wongboonsin, P., Carlos M.R.D. and Hatsukano, N. (2018) Filipino nurses’ employment opportunities in the non-nursing sector in Thailand, in BRC research Report no.22, Human Resource Development, Employment and Mobility of Health Professionals in Southeast Asia: The case of Nurses edited by Yuko Tsuzita, IDE/ JETRO Bangkok. Yeates, N. (2009) ‘Production for export: the role of the state in the development and operation of global care chains’, Population, Space and Place, 15, pp. 175–187. Yeates, N. and Pillinger, J. (2018) ‘International healthcare workers migration in Asia Pacific: International policy responses’, Asia Pacific Viewpoint, 59 (1), doi:10.1111/ apv.12180. Yeates, N., and Pillinger, J. (2019) International Health worker migration and recruitment: Global governance, politics and policy (1st ed.). Routledge. Zhu, J. (2012) Towards an understanding of nurses leaving nursing practice in China: A qualitative exploration of nurses leaving nursing practice from recruitment to final exit, Unpublished PHD Dissertation, University of Edinburgh. Available at: https:// era.ed.ac.uk/bitstream/handle/1842/7800/Zhu2012.pdf ?sequence=1andisAllowed=y, (Accessed 20 November 2021).

1

Nursing Education, Employment, and International Migration The Case of India Yuko Tsujita and Hisaya Oda

Introduction As estimated by the World Health Organization (WHO), approximately nine million additional nurses will be needed by 2030 to achieve universal coverage as a United Nation’s Sustainable Development Goal (WHO 2020). The ageing population, promotion of medical tourism, growing demand for better-quality health services, shift from family and home care to institutional care, and turnover of local nurses, have contributed to the higher demand for nurses worldwide (Tsujita and Komazawa 2020). With the COVID-19 pandemic, the global shortage of nurses has only been exacerbated. To address the national shortage of nurses, some countries choose to recruit health worker from international sources. India is one of the main source countries of nursing workforce. It supplies the highest number of nurses to the Organisation for Economic Co-operation and Development (OECD) countries after the Philippines. In total, 87,871 Indian-born nurses were working in OECD countries in 2015/16 (OECD 2020) and an estimated 640,000 are working abroad, including in the Gulf countries, which are nurses’ main destinations (Irudaya Rajan and Nair 2013). Therefore, India has become one of the largest ‘nurse exporters’ in the world. Meanwhile, the country suffers from a shortage of nurses. The number of nurses and midwives per 1,000 inhabitants in 2018 was only 1.7, while those for the world and OECD countries were 3.8 and 9.6, respectively (World Bank 2020). In particular, the shortage in rural areas in India is alarming, 73 out of the approximately 640 districts in the country have no registered nurses at all (Anand and Fan 2016). Owing to caste and religious norms, nursing is not traditionally regarded as a ‘good’ profession in India. The stigma and moral suspicion attached to nursing prevented many upper caste Hindus and Muslims from venturing into the profession (Johnson et al. 2014; Timmons et al. 2016). Moreover, as Christian missionaries played an important role in the introduction of modern nursing to India, women from Christian families have traditionally represented the majority of nurses nationally (Nair 2011; Hearly 2013; Reddy 2015). However, traditional constraints on occupational choice for women DOI: 10.4324/9781003218449-2

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have been gradually eroded by increased international employment opportunities. Indeed, becoming a nurse is increasingly regarded as a pathway to overseas employment. Thus, sending a child to a nursing college has become a prudent family strategy (Redfoot and Houser 2005; Percot and Irudaya Rajan 2007). While the nursing profession is still dominated by Christians today, some Hindus and Muslims, except for the majority of upper castes, choose to become a nurse. Taking into account this context, this chapter discusses the current issues in nursing education and employment in India. It demonstrates how nurses are educated, why they choose the nursing profession, and why some of them move abroad.

Methods This chapter draws on two surveys1 from the southern states of Tamil Nadu and Kerala, where the numbers of registered nurses are the highest and second highest in the country, respectively (Indian Nursing Council 2020). The first survey of undergraduate students studying nursing, in institutions regulated by the Indian Nursing Council Act (1947) was conducted in Kerala from January to February 2016, followed by one in Tamil Nadu from August to December 2016. By means of convenience sampling, students in three institutions in Thiruvananthapuram, the capital of Kerala, and two institutions in Chennai, the capital of Tamil Nadu, were interviewed. The number of sample students for this study was 218. The private institutions (hereafter private colleges) were established by a Muslim group, a non-religious group in Kerala, and a Christian group in Tamil Nadu. The sample population was restricted to final year students. The student survey was followed by interviews with principals and faculty members. Further, focus group discussions were conducted with students in 22 colleges in addition to five colleges where the above questionnaire survey was conducted. These interviews and focus group discussions were carried out between April 2016 and November 2017. The participants of the focus group discussions were invited from each college. The second survey of nurses in Chennai, Tamil Nadu was conducted from January to February 2016. Graduates of diploma courses at two nursing colleges were interviewed. One was a nursing college run by the state government (‘government college’) and the other was a private nursing college established by a Christian organisation. The study sample was composed of 193 graduates from the government college and 108 graduates from the private college. A total of 301 nurses, including 22 men, were surveyed. The year of graduation in this survey sample ranged from 1990 to 2013. Of the 301 nurses surveyed, 73 (24.3%) had already migrated abroad and were either back home or were still away from India at the time of the survey. A snowball sampling method was used to collect data. The questionnaire survey was mainly conducted in person. When respondents were located

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abroad, the interviews were conducted via telephone, e-mail, or social networking service applications.

Privatisation and Growth of Nursing Education Institutions In recent decades, growing global demand for nurses, coupled with privatisation in health, has led to the opening of a large number of private nursing colleges in India (Blythe and Baumann 2009; Spentz et al. 2014). Since the early 2000s, this growth was encouraged by the government’s National Health Policy (Government of India 2002) suggesting that specialised nurses need to be trained in larger scale. Consequently, the Indian Nursing Council, the regulatory body responsible for setting up and maintaining the nursing education and service standards, eased the criteria for establishing nursing education institutions and matters related to nursing courses in the late 2000s (Bablu 2009). In particular, the process of opening a nursing college offering four-year BSc. degree courses rather than a college of nursing offering three-year diploma courses (locally termed General Nursing and Midwifery courses) was simplified (Nair and Irudaya Rajan 2017). This change was partially driven by foreign employers’ demand for nurses with degrees rather than those with diplomas. In 2000, only 30 institutions offered a BSc. in Nursing, which had drastically increased to 1,996 by 2020; the corresponding numbers offering diploma courses in 2000 and 2020 were 285 and 3,185, respectively (Indian Nursing Council 2020). Table 1.1 illustrates this growth. Hence, although the number of BSc. courses has significantly increased in recent years, diploma graduates still outnumber BSc. degree graduates because diploma courses have lower tuition fees and more admission seats. This also indicates that diploma students can fill the shortage of nurses more quickly in Indian hospitals, as both diploma and BSc. holders become registered nurses in India once they pass the final exam in the course. The privatisation of nursing education provides the present generation with a greater opportunity to become nurses. However, nursing education has become a lucrative business. Some large healthcare groups in India invest USD 4,700–7,000 in training each nurse and earn as much as USD 47,000 once a student is placed abroad (Khadria 2007). Anecdotal evidence suggests Table 1.1 Number of nursing education institutions in India Year

Diploma

BSc.

2000 2005 2010 2015 2020

285 983 2083 2958 3185

30 377 1326 1690 1996

Source: Indian Nursing Council (2020)

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student nurses can also be used as ‘free labour’ or ‘helping hands’ in their healthcare facilities during training. The growing number of private institutions has created a problem with the quality of nursing education in India. As observed in this study, professional regulation and certification, which influence education quality, is relatively weak. The inspection and recognition of institutions fall within the purview of each state’s Nursing Council. Education standards across states differ, implying that the quality of nursing education is varied (Redfoot and Houser 2005). For example, as reported by Rao et al. (2011), 61% of nursing institutions are deemed unsuitable for teaching and have an acute shortage of faculty and clinical placement facilities. Our interviews with inspectors in southern India in 2016 and 2017 revealed that some private institutions often attempt ‘quick fixes’ such as improving physical infrastructure as well as clinical and teaching facilities at the time of the inspection. However, even unannounced inspections are unlikely to solve these problems owing to political pressure and inspector corruption (Oulton and Hickey 2009). In the worst cases, according to a state Nursing Council official we interviewed in 2016, some students plead with them for help, reporting daily that they pay high tuition fees for nursing education, but end up with ‘fake’ certificates without knowing that their education institution was not even recognised by the government.

Nursing Students’ Prospects This section discusses nursing students’ future employment preferences and opportunities for working in central government hospitals, state government hospitals, overseas hospitals, and private hospitals.2 The admission process for nursing courses in both Kerala and Tamil Nadu states is centralised and accounts for a number of criteria. A student is admitted based on their Higher Secondary School Certificate Examination (HSSCE) score as well as caste/community background at government colleges, and government quota at private colleges.3 Prospective students prefer government colleges, as the tuition fees are much lower with a better track-record of quality education they offer. According to the principals at each college, all the students in the government colleges covered by this study (see Table 1.2, A and C) passed their final examinations in 2015, while the pass rates for private colleges B, D, and E were 100%, 90%, and 86.7%, respectively. The survey found that 89 students (80.9%) at government colleges and 84 students (77.9%) at private colleges were interested in overseas employment opportunities. Preferred destination countries differed between the two groups; this is illustrated in Table 1.3. Students at government colleges tended to choose both Gulf states (31 students, 28.2%) and developed English-speaking countries such as Australia (31 students, 28.2%), Canada (14 students, 12.7%), the United States (13 students, 11.8%), the United Kingdom (12 students, 10.9%), and Singapore (10 students, 9.1%). Students at government colleges were more likely to have a

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Table 1.2 Background of BSc. in Nursing, from final year students’ survey State

Type of college

No. of final year sample students

Year nursing BSc. commended

No. of BSc. places per year when sample students were admitted

Annual tuition fee (INR)

A

Tamil Nadu

35

1983

35

7,500

B C

Tamil Nadu Kerala

24 75

2012 1972

25 75

40,000 18,000

D E

Kerala Kerala

Government Private Government Private Private

48 36

2007 2009

50 40

55,000 55,000

Source: Authors’ survey

Table 1.3 Nursing students’ intention to work overseas and their preferred destinations

No. of sample student nurses Those interested in overseas employment Preferred destinations (multiple choices) Gulf countries Australia Canada Ireland Singapore Switzerland United Kingdom United States

Government colleges

Private colleges

N

%

N

%

110 89

100.00 80.91

108 84

100.00 77.78

31 31 14 0 10 0 12 13

28.18 28.18 12.73 0.00 9.09 0.00 10.91 11.82

39 3 7 4 0 5 7 11

36.11 2.78 6.48 3.70 0.00 4.63 6.48 10.19

Source: Authors’ survey Note: Percentages are the proportion of students to the total sample in each college type.

nurse in their family (government colleges=55.5%; private colleges=43.5%), so they might have a network and more information on the overseas nursing labour market, particularly in the wealthy English-speaking countries in which Indian nurses work. Additionally, our focus group discussions suggested that student nurses mainly wanted to travel to certain countries because they had relatives

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residing there. These countries were popular not only on account of the higher salary, better working conditions, access to the latest technology, and training opportunities, but also because of the higher possibility of relocating their family and, more importantly, the higher respect and recognition paid to nurses in such countries. A student at government college C (Table 1.2 above) explained: My cousins are working in the UK as nurses. I know how much they can earn. That is one of the reasons why I would like to go there in the future, but more importantly, in India, the social status of nurses is low, but in some countries such as the UK and Australia…I heard that nurses are more respected by both doctors and patients. Nurses have more discretion [sic] in the workplace. Here, we just follow what doctors instruct nurses. Sometimes, patients treat us as if nurses are servants. That is why I would like to go there. (FGD, Student Nurse 3, Government College of Nursing C, 30 April 2016) Conversely, students at private colleges listed Gulf states (39 students, 36.1%) as the most popular destination by far, followed by other destinations (United States 11, Canada 7, United Kingdom 7, Switzerland 5, Ireland 4, and Australia 3). Although as indicated by our study participants, it was almost impossible to obtain citizenship in Gulf states, these countries were easier destinations to reach because the recruitment, processing, and travel expenses were lower than those for the UK, USA, Canada, Australia and New Zealand. And although an additional licensing exam and/or qualifications were usually required by some Gulf states, Indian nursing licenses were generally accepted, and no language qualification was required.4 Our interviews with principals of nursing colleges found that private colleges for nurses in India are well aware of students’ and their parents’ interest in overseas employment and some offer orientation on working abroad and/or plan to introduce the International English Language Testing System preparation course into their curriculum. Furthermore, our focus group discussions highlighted that some students preferred to work outside the state of origin, but within India where their mother tongue is not widely used, to improve their command of English, increase their market value, and enhance their employment opportunities abroad. Indeed, all private colleges in this study provided ‘campus recruitment’, which allowed private health facilities nationwide to promote them and ultimately recruit students on campus. However, although several sample students were interested in overseas employment, this was not their only option. In our sample, 86 of 110 students (79.1%) at government colleges and 72 of 108 students (66.7%) at private colleges were interested in both overseas employment and government jobs. Indeed, only three students (2.7%) at government colleges and 12 students

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(11.1%) at private colleges indicated that their future career plan was solely to work overseas, while 21 students (19.1%) at government colleges and 18 students (16.7%) at private colleges planned to take any state employment but were unwilling to work abroad, as shown in Table 1.4. Although government hospitals were an attractive option, those who would like to work in them had to pass a civil service examination, including the central government and state government exams. In total, 108 (98.2%) sample students at government colleges planned to take any civil service examination, which was more than their counterparts at private colleges (90 students, 83.3%). A noticeable difference between the two groups was found in terms of the desire to take the central government examination (79.1% at government colleges; 50.0% at private colleges). The central government examination was generally regarded as more competitive than the state government examination; it commanded better remuneration and working conditions than the state government examination did, and, unlike the latter, which was only held every few years, the central government examination was held every year. A male student at a government college in Kerala, who took part in our focus group discussion explained: I hope to work in a central government hospital. Well, it could be a state government hospital, but the state government exam is held only once every few years. I do not want to wait for the next state government exam. I need to earn a living, as I was born in humble circumstances. (FGD, Student Nurse 45, Government College of Nursing, Kerala, 15 July 2017) Many students try to pass any competitive government exam, and a few are even trying to work in non-nursing positions in the public sector, because it is Table 1.4 Nursing students’ preferred employment options

No. of sample student nurses To work overseas To work at government hospitals in India To work either overseas or at government hospitals in India Neither to work overseas nor to work at government hospitals Source: Authors’ survey

Government colleges

Private colleges

N

%

N

%

110 3 21

100.00 2.73 19.09

108 12 18

100.00 11.11 16.67

86

78.18

72

66.67

0

0.00

6

5.56

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23

more prestigious and regarded as higher status occupation than being a nurse. A faculty member at the Government College of Nursing C said: Many of our students in recent years have taken the civil service nursing exam, particularly the central government exam, after one year’s service. Bright students pass it the first time. Some have even tried the Indian Administrative Service (IAS). We have graduates who have become IAS officers. (Interview, Faculty Member 2, Government College of Nursing C: 30 April 2016) As our research findings revealed, many students in our survey intended to work at government hospitals (shown in Table 1.4 above). As a student at the Private College of Nursing stated that finding a job in a government hospital is more realistic than employment overseas: I will work at our college’s parent hospital after completing the course. Meanwhile, I will take the civil service exam. If opportunities arise and circumstances allow, I may go abroad. The civil service is a realistic target, but the expectation of overseas jobs is a fantasy. (FGD, Student Nurse 38, Private College of Nursing, 15 July 2017) A student at a Government College of Nursing in Kerala explains further: I am engaged…my fiancé is originally from India and his family have settled in the United States. So, I will work in the United States as a nurse, just like my mother-in-law to-be does. Cases like mine are exceptional; many of my classmates are rather indecisive about going abroad, but they are certain about taking the civil service exam. (FGD, Student Nurse 30, Government College of Nursing, Kerala, 14 July 2017) Importantly, those who listed finding a job oversees as a reason for studying nursing were planning to take the civil service exam. Notably, 81 out of 83 students (97.6%) at government colleges and 73 out of 84 students (86.9%) at private colleges answered so. This indicates that overseas employment does not necessarily outweigh government jobs even though their initial intention to become a nurse is to work abroad. A student at the Private College of Nursing explained: I will work at a private hospital immediately after graduation. However, I will try the state government exam when it is held next time. Government jobs are secure, while private hospitals and even overseas hospitals have no job security. (FGD, Student Nurse 65, Private College of Nursing D, 15 November, 2017)

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A principal of a Government College of Nursing in Kerala stated: Many of our graduates work abroad because there is huge demand for nurses in Western countries from time to time. However, students in the recent past have increasingly intended to work in state hospitals. If they cannot get a position in a state hospital, they try hard to go abroad. Even if they pass the civil service exam, some of them may take leave to work abroad for some years for financial and other reasons. As foreign countries may open their nursing labour market at some point but may close at any time, they keep their civil service job because they can always come back here. High wages abroad are not enough. Job security in India is also important and attractive. (Interview, Faculty Member 18, Government College of Nursing, 15 July 2017) The survey questionnaire and focus group discussions clearly indicates that nurse students are interested not only in overseas employment but also in working at government hospitals. In many cases, the latter plays an important role in defining their prospective career paths.

International Migration: Nurses from Tamil Nadu Based on the survey conducted in Chennai, Tamil Nadu in 2016, this section discusses in more detail the international migration as a career path for Indian nurses. It addresses the questions of who migrates, where and why. This section also examines how international migration influences the career development of returned nurses. Career Choices for Nurses: National, and International Destinations As revealed in our study, the desire for international migration is high among nurses working at private hospitals. Table 1.5 shows the distribution of nurses by the type of college they attended and type of hospital they worked at immediately after graduating. Of the 193 students at government colleges, 131 (67.9%) took their first nursing job at government hospitals, while 60 (31.1%) took a job at private hospitals. Two nurses left immediately for overseas employment, one to Italy and one to Dubai. All of the 108 students at private colleges found their first nursing job at private hospitals. This skewed recruitment and employment pattern is mainly due to the long-standing practice in India where nurses at government hospitals and other government health facilities are recruited only from graduates of government colleges. After long legal battles, the door to the government sector employment was opened to graduates from private nursing colleges in 2015; however, government positions are still usually filled by graduates from government colleges.

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25

Table 1.5 Placement by the type of hospital and college

Private College Government College Total

Government hospital

Private hospital

Overseas hospital

Total

no.

%

no.

%

no.

%

no.

%

0 131

0.0% 67.9%

108 60

100% 31.1%

0 2

0.0% 1.0%

108 193

100% 100%

131

43.5%

168

55.8%

2

0.7%

301

100%

Source: Authors’ survey

Several studies have found that international migration among nurses working at private hospitals is higher than that among those working at government hospitals (Thomas 2006; Walton-Roberts et al. 2017; Oda et al. 2018). Table 1.6 presents international migration by college and hospital types, showing the number of international migrants in each category; the percentages are calculated based on the number of nurses in each category. The percentage of international migration among nurses working in private hospitals (31%) is higher than that among those at government hospitals (14.5%). This pattern is particularly high among nurses who graduated from a private college (35.2%). A similar trend is observed among government college graduates, with the rate of migration for nurses working at private hospitals (23.3%) higher than that for those working at government hospitals (14.5%). In terms of migration destinations, the Malay Peninsula, Singapore and Gulf countries are the three major destinations, with Malaysia (26.0%, 19 nurses) in first place, Singapore (16.4%, 12 nurses) in second place, Saudi Arabia (13.7%, 10 nurses) in third place, and the UAE (9.6%, seven nurses) in fourth place. While the Gulf region has generally been a major destination for Indian workers, including nurses, the choice of Tamils to migrate to Malaysia and Singapore may reflect not only its geographical proximity, but also its Table 1.6 International migration by the type of hospital and college

Private College Government College Total

Government hospital

Private hospital

Overseas hospital

Total

no.

%

no.

%

no.

%

no.

%

0 19

0.0% 14.5%

38 14

35.2% 23.3%

0 2

0.0% 100.0%

38 35

35.2% 18.1%

19

14.5%

52

31.0%

2

100.0%

73

24.3%

Source: Authors’ survey *Percentage figures are calculated by dividing the number of international migrants by the total number of nurses in each category.

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historical links. Between 1840 and 1940, during the British Raj, four million Tamils migrated to the Malaya Peninsula to work on plantations or carry out agricultural and domestic work (Amrith 2010; Irudaya Rajan et al. 2016). Most Indians in Malaysia and Singapore are descendants of these Tamil workers and have established Tamil communities.5 Tamil workers, including nurses, are thus more willing to migrate to these areas because of the large population of Tamils in these countries. While Malaysia, Singapore, and the Gulf region are the main destinations for migration, some nurses have also migrated to Australia (five nurses), the United Kingdom (three nurses), and Ireland (three nurses). Reasons for International Migration In the survey, nurses with migration experience were asked their most important reasons for the international move. One of the three major reasons, as nurses revealed, was the low salary in India. As Table 1.7 shows, 15 out of 66 respondents (22.7%) stated that seeking a higher income and a better life was the most compelling reason for migration. In particular, 13 nurses (19.7%) had worked at a private hospital before migrating. This result clearly indicates that the low salary is a motivating factor for nurses at private hospitals to emigrate. Although some high-end private hospitals pay salaries comparable to those of government hospitals, salaries vary depending on location, duties, and experience. Generally, salaries for nurses at private hospitals are low. According to a nurse recruitment and placement agency in Tamil Nadu, the average basic salary at private hospitals (in June 2021) was around INR 16,000 per month.6 This figure is probably about average for a relatively large hospital in an urban area; nurses working at small hospitals or clinics may earn less than this amount.7 Even INR 16,000 per month is less than half the salary of a state government nurse (INR 30,000–40,000 per month). In the most destination countries in the Gulf and Singapore, nurses who migrate Table 1.7 Reasons for international migration by hospital type

Private hospital Government hospital Total

High social status/ recognition

Higher income and better life for family

5

13

6

4

0

2

5

5

15

11

Source: Authors’ survey

Children’s future/ education

Education and skill development

Marriage reason

More selfconfidence in decision making

Improvement of professional skills

Total

9

1

11

49

1

5

0

4

17

5

14

1

15

66

Nursing education, employment, and international migration

27

are required to have at least two to three years of nursing experience (Garner et al. 2015; Timmons et al. 2016). Hence, anecdotal evidence suggests that some nurses at private hospitals work without pay to gain the experience needed to emigrate. Low salaries are not the only reason to migrate. Professional aspiration such as learning new nursing skills is also an important factor. Overall, in our study, 22.7% of respondents indicated that improving their skills was their main reason for moving abroad. Similar to the case of low salaries above, 11 nurses (22.4%) working at private hospitals considered this to be the most important factor. Many nurses working at private hospitals reported that they lacked modern and advanced facilities to improve their professional skills. The third factor is family reasons, with 14 nurses (21.2%) citing marriage as a primary reason for migration (i.e. the spouse emigrates and the nurse follows them). Even if a nurse migrates due to marriage, they are still working as a nurse in the destination country in some cases. Nurse migration as a family dependent can be considered as a sort of family strategy that uses the spouse’s migration to avoid the bureaucratic procedures required for nurses to migrate. This practice has been used in the case of migration to Emigration Check Required (ECR) countries, many of which recognise the Indian nursing license. Since 2015, nurses who wish to work in these 18 countries, including the Gulf countries and Malaysia, must pass through six state-run recruitment agencies and obtain emigration clearance from the Protector of Emigrants office.8 These are the main destinations for Indian nurses. Although this measure was introduced to protect nurses from exploitation and fraud in the recruitment process, it has become a factor impeding the migration of Indian nurses to these countries. In addition to these reasons, precarious employment, the lack of fringe benefits such as pensions after retirement, the lack of opportunities for promotion, no clear career pathway, and poor working conditions at private hospitals also encourage nurses to migrate.

International Mobility and Career Development This section analyses the career development of migrant nurses after they return to India after a period of employment from overseas, and assesses the impact of international migration on their career development. Tables 1.8(a) and 1.8(b) show the changes in workplace between immediately after leaving college and at the time of survey. The 39 nurses who left India and had not returned at the time of the survey were excluded. Among government college graduates, the number of nurses working at private hospitals decreased significantly from 54 to 15, while the number of nurses working in government hospitals drastically increased from 121 to 160. This was mainly caused by the change in workplace from private to government hospitals. On the contrary, there was no noticeable change among nurses who graduated from a private college. This career move

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Table 1.8(a) Current workplace by college type: nurses graduated from government school First workplace

Current workplace

Government hospital Private hospital Total

119

2 121

Government hospital 68.0% 41

Private hospital

Total

23.4%

160

91.4%

1.1%

13

7.4%

15

8.6%

69.1%

54

30.9%

175

100%

Table 1.8(b) Current workplace by college type nurses graduated from private school First workplace

Current workplace

Government hospital Private hospital Total

Private hospital

Total

0

Government hospital 0.0% 4

4.6%

4

4.6%

0

0.0%

83

95.4%

83

95.4%

0

0.0%

87

100%

87

100%

Source: Authors’ survey *Percentage figures are calculated by dividing the number of nurses in each cell by the total number of nurses. **This table excludes the data for 39 nurses who left India and had not returned at the time of the survey.

illustrates the strong preference for government hospitals and hierarchy in Indian hospitals. As the previous section discusses, nurses in India generally prefer to work at government hospitals because of the better working conditions, including higher salary and better skill development opportunities. Of the eight returning nurses who graduated from a government college and worked at private hospitals before their migration, four successfully obtained nursing positions at government hospitals after they returned to India following a period of overseas employment. On the contrary, of the 17 returnee nurses who graduated from a private college and used to work at private hospitals prior to their migration, only one nurse secured a position at a government hospital after her return to India. Although it is not possible to come to a definitive conclusion from these few observations, government college-educated nurses could be using international migration as leverage to upgrade their future jobs prospect, whereas it may be difficult for private college-educated nurses to do so.

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The difference in the types of workplace between nurses who graduated from private and government colleges can be attributed to differences in the quality of education and academic performance of students, in addition to the long-standing practice of recruiting nurses who only graduated from government colleges, which was in place until 2015.9 As nurses graduating from private colleges find it difficult to secure jobs at government hospitals, they strategically use international migration as an employment opportunity to obtain a better salary and higher skill development abroad, however on their return to India, they may still struggle to find a place in the government hospital.

Discussion: Professional Nursing and Labour Market in India It emerged from the findings that career options formed a hierarchy, with the relative attractiveness of a job at a government hospital at the top, followed by overseas jobs, and private hospitals in India at the bottom. Study findings indicate that except for the minority of sample students who were able to emigrate after their graduation, many participants tried to pass the competitive civil service exam first rather than finding employment abroad. Most importantly, this chapter highlights that nurses might not emigrate if their jobs are reasonably paid and secure in India, although their reward is not as high as the potential earnings abroad. If they fail to secure a job in the government hospital, they are more likely to seek for work abroad. Indeed, this study on alumni nurses found that those who worked at private hospitals were more likely to work abroad than those who worked at government hospitals. Even after returning to India after a period of work abroad, nurses still preferred to work at government hospitals because of the difference in salaries and working conditions between government and private hospitals. Compared with private hospitals in India, government hospitals offer higher basic pay, various benefits and allowances, annual salary increments, greater job security, and better working conditions (Oda et al. 2018).10 Anecdotal evidence suggests that only a small proportion of nurses at high-end private hospitals with the latest facilities and equipment can earn as much as those in government hospitals. Nevertheless, owing to the many applicants to the limited jobs at government hospitals, nurses found it difficult to obtain a position at government hospitals, even when they advance their career abroad. This is particularly so for those who graduated from private nursing college because of not only the traditional practice of government hospitals in Tamil Nadu recruiting nurses who graduated from government colleges until recent years, but also the higher quality of education at government colleges than some private colleges in both states. This chapter thus shows the association between the type of nursing college and type of hospital at which graduate nurses work. Nurses at government hospitals who often graduated from government colleges tend to stay in India

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Yuko Tsujita and Hisaya Oda

more than their counterpart nurses at private hospitals who generally graduated from private colleges. The reason not to emigrate is mainly due to the higher salary, better working environment, and greater job security in government hospitals, as well as that overseas jobs are not always secure. The Indian Nursing Council has stipulated that the minimum wage for nurses at private hospitals should be INR 20,000 per month (Times of India 2016). Consequently, in 2018, the state government of Tamil Nadu set the minimum wage lower than INR 20,000 (Government of Tamil Nadu 2018), while the state government of Kerala set this (i.e. INR 20,000) as the minimum wage (Government of Kerala 2018). However, according to our interviews with nurses in Kerala in May 2019, some hospitals paid this amount, while others did not, and in the hospitals that paid the minimum wage, the number of nurses had fallen. Moreover, owing to fiscal constraints, there were an increasing number of contract-based nursing positions in government health facilities for much lower wages and under much inferior conditions than nurses on permanent positions (Kurup 2012). This further contributes to the existing shortage of nurses, as potential nursing staff prefer to be unemployed or await recruitment into permanent positions instead of working for low wages and in inferior working conditions in state health facilities. Although some nurses who were inactive at the time were recruited to fill the vacant nursing positions in state hospitals during the COVID-19 pandemic, several vacancies remained. Nurses are reluctant to take these vacant positions because the contract period during the COVID-19 pandemic tended to be shorter than usual, such as one month or three months (Johari 2021). Fiscal constraints have also affected the employment conditions with permanent contracts. For example, the state pension schemes have changed, from a statutory scheme (i.e. no contribution from employees during their working years) to a contribution scheme (i.e. employees meet the cost of a specified proportion).11 The poorer the working conditions hospitals offer nurses, the more likely it is that those who might have worked in them seek overseas employment. Even if they join state services and complete the probation period, they might still be more inclined to take leave, work abroad, and not return for a long time once their government job has been secured.12 We came across such nurses more often in Kerala than in Tamil Nadu.13 As the relative advantages of a government job in terms of salary and working conditions are eroded, the hierarchy of job preferences might change and a large-scale exodus of nurses from India might ensue.

Contributions and Limitations This study employed convenience sampling to select nursing colleges and snowball sampling to recruit graduate nurses because of the unavailability of a list of graduates at the selected colleges. Therefore, these results are rather

Nursing education, employment, and international migration

31

indicative and illustrate some of the existing experiences among graduate nurses. Additionally, the study context—student nurses at five colleges in Tamil Nadu and Kerala and graduates from two nursing colleges in Tamil Nadu—is unique. Therefore, it may not be appropriate to generalise these results to the whole population of student nurses and graduate nurses in the country. However, this chapter provides insights into the employment preferences and career experiences of student nurses. This study’s findings are consistent with the existing literature on international nurse migration from India that finds a higher incidence of international migration of nurses who work at private hospitals than government hospitals (Thomas 2006; WaltonRoberts et al. 2017; Oda et al. 2018). At the same time, this study is the first to identify that the type of nursing college and a hospital type (government or private) are closely associated and that a hierarchy of job preferences exists for nursing students and nurses. These affect the incidence of international migration.

Conclusion This chapter highlighted the current scenario of nursing education in India and showed why some nurses are motivated to work abroad. Nurses tend to prefer to work at government hospitals rather than private hospitals because the former offer much higher salaries, better benefits, and more job security, among other favourable conditions. This is also related to international nurse migration from India. Those who work abroad tend to have worked at private hospitals in India. The recent increase in recruiting contract-based nurses at government hospitals might increase the amount of international migration from India, which is beleaguered by a shortage of nurses. The Indian government has been playing a facilitating role in emigration (Irudaya Rajan et al. 2017). Nurses move abroad to work without registering their departure or the government’s protection. With increasing malpractice such as financial disagreements between private recruiters and nurses and the violation of human rights in some foreign countries (Kingma 2006; George 2015), the Indian government has restricted recruitment to authorised public recruitment agencies when working as a nurse in 18 countries; in Gulf, African, and Asian countries.14 Mandatory emigration clearance from the Protector of Emigrants was introduced in April 2015 by the Indian government. However, recruitment through this route remains limited (Walton-Roberts and Irudaya Rajan 2020).15 Given rising demand for nurses, particularly in affluent countries, more nurses might decide to emigrate to those countries. Indian policymakers should closely monitor and regulate private recruiters, including subcontracting recruiters, in all nurses’ destinations. Most importantly, unless decent pay is ensured and working conditions improved, India will remain one of the main suppliers of nurses worldwide, while it suffers a shortage of nurses domestically.

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Notes 1 These surveys were jointly conducted by the Institute of Developing Economies (IDE-JETRO), Centre for Development Studies, Thiruvananthapuram and the Loyola Institute of Social Training and Research, Chennai. Both are funded by the IDE-JETRO. Apart from these two surveys, this chapter refers to results of other studies conducted about Indian nurses. Where relevant, appropriate references are included in the text. 2 This discussion is based on the analysis of survey responses provided by 218 final year students at five nursing colleges (see Table 1.2). 3 Notably, only 35% to 50% in the case of minority institutions established and administered by minorities in terms of religion and language in Tamil Nadu and 50% of admissions in Kerala to most private institutions are at the discretion of the institution’s management, while the remaining students are allotted through the merit list and counselling (in which students are told which colleges are available) provided by each state government. 4 In OECD countries, Indian nurses are required to sit the licensing exam to work as a nurse (e.g. United States, Singapore) or take part in bridging training courses after their qualification and careers are assessed (e.g. Australia, New Zealand). 5 Tamil is one of the four official languages in Singapore. 6 The salary figure was accessed from https://in.indeed.com/career/nurse/salaries/ Tamil-Nadu (accessed on 24 June 2021). 7 Our survey in Uttar Pradesh in 2018–19 found that nurses working for clinics and hospitals in small towns earn between INR 5,000 and 8,000 per month, while nurses at the Primary Healthcare Centre, run by the state government, receive INR 30,000 per month. 8 See Walton-Roberts and Irudaya Rajan (2020) for a brief discussion on Emigration Check Required restrictions. 9 See The Hindu (2015). 10 The salary gap between central government, state government, and private sector is significant. For example, according to a nurses’ union leader in May 2019, the starting salaries including various allowances at central government and state government hospitals in Kerala were approximately INR 68,000 and INR 32,000, respectively. Whereas, at private hospitals, newly graduated nurses earned on average INR 5,000–6,000 per month. A media report suggests that nurses in private hospitals earn one-third of what government hospital nurses earn (https://www. livemint.com/news/india/rs-20-000-minimum-wage-for-nurses-what-it-means-forcorporate-hospitals-1565673899224.html) accessed on 4 October 2021. 11 See https://www.pfrda.org.in/myauth/admin/showimg.cshtml?ID=417 in the case of Tamil Nadu and http://finance.kerala.gov.in/npsinfo.jsp in the case of Kerala (accessed 4 October 2021). 12 Government employees in the state of Kerala used to take leave without pay up to 20 years, however it is reported to have reduced to five years in 2020 (Mathrubhumi 2020). 13 In Tamil Nadu, as nurses at government hospitals are entitled to a provision of ‘leave’, it is thus easier for them to obtain leave (up to five years). However, it is becoming increasingly difficult to do this. Although the same provision still exists, fewer nurses receive permission for extended leave and subsequently return to the payroll, according to our interviews with nurses at government hospitals. 14 These 18 countries include Afghanistan, Bahrain, Indonesia, Iraq, Jordan, Kuwait, Lebanon, Libya, Malaysia, Oman, Qatar, Saudi Arabia, South Sudan, Sudan, Syria, Thailand, United Arab Emirates and Yemen. 15 Some private agencies were allowed to recruit nurses from 2016 (Kudoth 2021).

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Khadria, B. (2007) ‘International nurse recruitment in India’, Health Services Research, 42 (3 Pt 2), pp. 1429–1436, doi:10.1111/j.1475-6773.2007.00718.x. Kingma, M. (2006) Nurses on the move: Migration and the global health care economy, Ithaca: Cornell University Press. Kurup, D. (2012) ‘Angels of mercy themselves need a lot of it’, The Hindu, 20 March 2012. Available at: https://www.thehindu.com/news/cities/bangalore/angels-of-mercythemselves-need-a-lot-of-it/article3015693.ece (Accessed on 22 September 2021). Kudoth, P. (2021) ‘State policy and recruitment of domestic workers and nurses to est Asia: a comparative political economy analysis’, Economic and Political Weekly, 56 (36), pp. 37–44. Mathrubhumi (2020) ‘Kerala govt reduces leave without pay to 5 years’, 16 September. Available at: https://english.mathrubhumi.com/news/kerala/kerala-govt-reduces-leavewithout-pay-to-5-years-1.5057702 (Accessed: 24 November 2021). Nair, S. (2011) Moving with times: Gender, status and migration of nurses in India, New Delhi: Routledge. Nair, S. and Irudaya Rajan, S. (2017) ‘Nursing education in India: changing facets and emerging trends’, Economic and Political Weekly, 52 (24), pp. 38–42. GoI – Government of India (2002) National Health Policy. Available at: https://main. mohfw.gov.in/sites/default/files/18048892912105179110National.pdf (Accessed: 19 May 2021). Oda, H., Tsujita, Y. and Irudaya Rajan, S. (2018) ‘An analysis of factors influencing the international migration of Indian nurses’, Journal of International Migration and Integration, 19 (3), pp. 607–624. doi: https://doi.org/10.1007/s12134-018-0548-2 OECD – Organisation for Economic Cooperation and Development (2020) ‘Contribution to migrant doctors and nurses to tackling COVID-19 crisis in OECD countries’, OECD, 13 May 2020. Available at: https://www.oecd.org/coronavirus/p olicy-responses/contribution-of-migrant-doctors-and-nurses-to-tackling-cov id-19-crisis-in-oecd-countries-2f7bace2/ (Accessed: 17 May 2021). Oulton, J. and Hickey, B. (2009) ‘Review of the nursing crisis in Bangladesh, India, Nepal and Pakistan’, Draft for Internal Review, Barcelona: Instituto de Cooperation Social Integrate S.L. Percot, M. and Irudaya Rajan, S. (2007) ‘Female emigration from India: Case study of nurses’, Economic and Political Weekly, 42 (4), pp. 318–325. Rao, M., Rao K.D., Shiva Kumar, A.K., Chatterjee M., Chatterjee, M. and Sundararaman T. (2011) ‘Human resources for health in India’, Lancet, 377 (9765), pp. 587–598, doi: https://doi.org/10.1016/S0140-6736(10)61888-0. Reddy, S.K. (2015) Nursing and empire: Gendered labor and migration from India to the United States, Chapel Hill: University of North Carolina Press. Redfoot, D.L. and Houser, A.N. (2005) We shall travel on: Quality of care, economic development, and the international migration of long-term care workers, Washington, DC: AARP Public Policy Institute. Spentz, J., Gates, M., and Jones, C.B. (2014) ‘Internationally educated nurses in the Unidad States: Their Origins and Roles’, Nursing Outlook, 62 (1), pp. 8–15, doi: https://doi.org/10.1016/j.outlook.2013.05.001. The Hindu (2015) ‘Right to Govt. jobs for private college nurses got after long legal battle’,15 January. Available at: https://www.thehindu.com/news/national/tamil-nadu/ right-to-govt-jobs-for-private-college-nurses-got-after-long-legal-battle/article6779873. ece (Accessed: 1 May 2021).

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Thomas, P. (2006) ‘The international migration of Indian nurses’, International Nursing Review, 53 (4), pp. 271–283, doi: https://doi.org/10.1111/j.1466-7657.2006.00494.x. Times of India (2016) ‘Now equal pay for private and state-run hospital nurses, recommends committee set up by the Indian Nursing Council’, 23 September. Available at: https://timesofindia.indiatimes.com/city/mumbai/now-equal-pay-for-privateand-state-run-hospital-nurses-recommends-committee-set-up-by-the-indian-nursingcouncil/articleshow/54471610.cms (Accessed: 20 May 2021). Timmons S., Evans, C. and Nair, S. (2016) ‘The development of the nursing profession in a globalized context: A qualitative case study in Kerala, India’, Social Science and Medicine, 166, pp. 41–48, doi:10.1016/j.socscimed.2016.08.012. Tsujita, Y. and Komazawa, O. (2020) Human resources for the health and long-term care of older persons in Asia, Economic Research Institute for ASEAN, Jakarta and East Asia and Institute of Developing Economies, Chiba, Japan. Walton-Roberts, M. and Irudaya Rajan, S. (2020) ‘Global demand for medical professionals drives Indians abroad despite acute domestic health-care worker shortages’, Migration Policy Institute. Available at: https://www.migrationpolicy.org/article/globaldemand-medical-professionals-drives-india (Accessed: 1 June 2021). Walton-Roberts, M., Runnels, V., Irudaya Rajan, S., Sood, A., Nair, S. et al. (2017) ‘Causes, consequences, and policy responses to the migration of health workers: Key findings from India’, Human Resources for Health, 15 (28). doi: https://doi.org/ 10.1186/s12960-017-0199-y. WHO – World Health Organization (2020) ‘Nursing and midwifery’. Available at https:// www.who.int/news-room/fact-sheets/detail/nursing-and-midwifery (Accessed 27 November 2021). World Bank (2020) ‘Nurses and midwives (per 1,000 people)’. Available at: https://data. worldbank.org/indicator/SH.MED.NUMW.P3 (Accessed: 22 September 2021).

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“Friendly relations” in troubled times Tracing a decade of nurse migration from India to the UAE1 Margaret Walton-Roberts and Binod Khadria

Introduction The United Arab Emirates (UAE) is one of the richest countries in the Middle East (aka West Asia) and a prominent member of the Gulf Cooperation Council (GCC). The Indian population in UAE is one of the largest Indian diasporic populations at an estimated 3.4 million people, among a world total of 32 million (Calabrese 2020). A dominant part of this diaspora comprises nurses qualified in India, who also form a significant portion of internationally educated nurses working overseas.2 An estimated 33,147 Indian nurses were working in member countries of the Organisation for Economic Co-operation and Development (OECD) countries in 2016. In the United States, nurses qualified in India account for 9% of all non-US educated migrant nursing workforce (WHO 2017, p.11). Other major destination countries for Indian nurses include Australia, Bahrain, Canada, Kuwait, Saudi Arabia, the UAE, and the United Kingdom. Most of these nurses come from the Indian state of Kerala. Estimates suggest over 30% of nurses who studied in Kerala work in the United Kingdom or the United States of America, with 15% in Australia and 12% in the Middle East (WHO 2017). Figure 2.11 provides a bird’s-eye-view of the various destinations where nurses from Kerala worked in 2016. The share of Indian nurses in the UAE reflects the significant relationship between these two nations in terms of human resources for health. We consider the provision of nurses is part of a growing bilateral relationship focused on health between the two countries, but one that is not formally or fully recognised or advanced through bilateral or diplomatic agreements between the two nations. The importance of more formal recognition and negotiation regarding the contribution of Indian nurses to UAE’s health system is necessary when we consider India’s own position regarding human resources for health. A recent study on the stock and active workforce of health workers in India reveals estimates well below the World Health Organisation (WHO) threshold of 44.5 doctors, nurses, and midwives per 10,000 population (NHWA 2018, cited in Karan et al. 2021). The results also reflect a highly skewed distribution of health workforce across India’s states, rural–urban and public–private sectors. Many are DOI: 10.4324/9781003218449-3

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Fig 2.1 Percentage distribution by locations of nurses from Kerala in 2016 Source: adapted from WHO 2017

not adequately qualified and at least one-fifth of those qualified are not active participants in the labour markets (Karan et al. 2021). The number of skilled health workforce are predicted to increase from the latest estimates of 1.77 million in 2021 to 2.65 million by 2030 (Karan et al. 2021). But this would still not lead to an enhancement in the density of skilled health human resources beyond 17.5 per 10,000 population in 2030, reflecting a shortfall of about 1.13 million workers. To reach the WHO threshold of 44.5 health workers per 10,000 population in India, India would require a 200% growth by 2030, resulting in 2.02 million nurses and 3.45 million of the overall skilled health workers in 2030 (i.e., an addition of 22.76 skilled health professionals per 10,000 population) (Karan et al. 2021, p.6). This provides important context for the examination of India–UAE relations in health care worker mobility and health care investments.

Background on the nature of international relations and the Indian diaspora in UAE India and the UAE have enjoyed diplomatic relations since 1972, but trade and commercial relations have significantly increased since the 1990s when the UAE became a regional trading hub and India liberalised its economy (Embassy of India, n.d. “Economic and Commercial Relations”). Exports and investment flows between the two countries are diversified, with India being UAE’s second largest trading partner, and the UAE India’s third largest trading partner. The Indian diaspora were the largest foreign investors in Dubai real estate in 2016–17 (Embassy of India, n.d. “Economic and Commercial Relations”). Indian migrant workers in the UAE span the skills spectrum, filling all occupations from low to mid to high skilled (Naufal et al. 2016). UAE cities such as Dubai and Sharjah are seen as “ideal compromises” for transnational

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Indian families in search of cultural and economic security; these destinations are closer to India than the UK or USA for extended family connection, yet more modern than India in terms of health and education facilities (Osella and Osella 2008). Indian nurses have long been attracted to the working career and living opportunities available in UAE as a “hub” of migrant workers and professionals (Khadria 2020). The region also acts as an important node in a step-wise migration pathway to European and North American markets that Indian nurses have engaged in for decades (Percot 2006). Most of the migrant Indian nurses in UAE come from the South-Indian state of Kerala as the “hinterland” of migrant workers (Khadria 2020). The UAE, as with other GCC locations, provides a valuable working option for nurses seeking to migrate eventually to OECD nations such as UK, USA, Canada, and Australia. Entry to the GCC nations is relatively more straightforward than moving directly to OECD nations, and this two-step migration, in terms of moving from one region onto another, also provides a channel to bypass or circumvent the “ethical recruitment practices” propagated by the WHO3 (Khadria 2012). The region provides an effective corridor to be used for “step-wise migration” to more developed countries and regions, and as such comprises part of a wider global circulatory migration network for Indian nurses.

Bilateral relations, investments in healthcare and health worker mobility Indian corporate health groups value international training and experience; indeed, many have international partnerships that facilitate health worker exchanges and they leverage their internationalism to promote medical tourism to India.4 Both the UAE and India are significant health care destinations due to the provision of quality but affordable health care, and Dubai is emerging as a major medical tourism hub that employs over 35,000 health professionals from over 100 countries (Al-Talabani et al. 2019). The UAE is an important base for Indian-owned healthcare groups such as Aster DM Healthcare Limited. Founded in 1987 by Azad Moopen from Kerala, and a publicly traded Indian conglomerate health care provider registered in India, Aster DM Healthcare currently runs 27 hospitals and 115 clinics in the GCC and India.5 While India’s domestic health system is ranked at 112 in the WHO’s ranking of health systems, the global health sector is increasingly recognised as an important and growing economic driver globally worth $8 trillion (The Hindu 2018). The health sector is also the largest employer in the world – with a potential shortage of 80.2 million workers by 2030 globally (WHO 2016). Dr Devi Shetty, Chairman of Narayana Group of Hospitals, an internationally reputed cardiologist, and a public health intellectual, while delivering the keynote address at the Confederation of Indian Industry (CII) Karnataka’s Annual Day referred to the potential of India to earn potentially $100 billion annually by training significant numbers of health professionals (The Hindu

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2018). He also commented that India’s health professions already provide significant employment, especially for women, and occupational restructuring might increase efficiencies in the delivery of health services while boosting employment. Comments such as these highlight the economic potential for India to service the human resources for health demands of the world. The dispersion of Indian nurses globally, including to the UAE and other GCC nations, suggests this is already a well-established sector. However, maximising on this migratory flow is compromised by various market failures in terms of domestic education and preparation and inefficient or sub optimal integration at destination and transit sites.

Rise in nurse education, nurse migration and conditions of employment India has shown significant rise in its capacity to educate nurses over the recent decades. The aggregate number of institutions offering Bachelor of Science qualifications (BSc., Nursing) was 349 in 2005, registering an over fivefold increase to 1,831 by 2016, whereas the institutions offering Master of Science (MSc.) degrees grew almost 12 times from 54 to 637 over the same duration (WHO 2017, p.7). The number of institutions offering Diplomas (Auxiliary Nursing and Midwifery qualifications) went up from 254 to 1,986 during the same period, whereas those supplying General Nursing and Midwifery qualifications grew from 979 to 3,123 (Indian Nursing Council data, cited in WHO 2017). This growth was also due to the expansion of the private sector institutions in the health sector, which was in response to not only rising national and global demand for nurses but also encouragement to privatisation of the services sectors. For Auxiliary Nursing and Midwifery institutions, the private sector institutions comprised 85% in 2016, whereas General Nursing and Midwifery, BSc. and MSc. institutions made up 90% of the total. What is most striking about India’s nursing scenario is that more than half of the country’s nursing schools and education institutions are located in the four southern states, viz., Kerala, Tamil Nadu, Karnataka, and Andhra Pradesh. There is a substantial schism between the fee levels at the government institutions and the private institutions, the former being highly subsidised and the latter being the profit-making ones. Nurses in India are educated at a variety of qualification types and levels. Auxiliary nurse-midwife (ANM) is the basic level nurse, mostly located at primary health centres and providing community outreach services like vaccinations. Next, the general nurse midwife (GNM, having a General Nursing and Midwifery diploma) is the most common type of nurse employed in a range of public and private health facilities, ranging from Public Health Centres to tertiary hospitals. A smaller set of nurses are those holding a bachelor’s degree and above, which is the minimum training required in the OECD countries, and increasingly also in GCC countries. At the next level are the MSc. (Nursing) degree holder who can become nursing school

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instructors (Indian Nursing Council cited in WHO 2017). However, as with other categories of health professionals in India, many “nurses” are working without the requisite qualification. For example, one study has cited an estimate that in 2012, 58.4% of those claiming to work as nurses did not have the requisite qualification (WHO 2017). Another study concluded that 67.1% of nurses and midwives in 2001 were educated only up to the secondary level, despite that the minimum education in Auxiliary Nursing and Midwifery was a two-year post-secondary formal training (Anand and Fan 2016). Most nursing education seats in India and Kerala are in the private sector, but between 2012 and 2016, the public nursing institutions experienced a faster growth than in the private sector, reflecting enhanced deployment of public funding in nursing education (WHO 2017). During the same period, Kerala registered a growth of almost 23% in the government sector and 1.1% in the private colleges. Institution wise, the overall growth of nursing seats in India during the same period grew by 17.7%, resulting from 46% growth of seats in government institutions and 15% in private sector institutions (WHO 2017). The Indian Nursing Council (INC) established with the Indian Nursing Council Act of 1947, governs nursing education in India.6 It advises state nursing councils, examining boards, state governments and the central government in matters related to nursing education. The INC is responsible for several functions, such as setting curricula for nurse education, maintaining quality standards in nurse education institutes, recognising nursing institutes, and registering nursing graduates from degree, diploma, and certificate programmes. Along with regulating nursing education and research, it is also responsible for the code of conduct and ethics. The Nursing Council of India is the Indian government agency responsible for all these functions.7 Further, the Protectorate of Emigrants (POE) and the National Commission for Women (NCW) particularly monitor the safety of emigrant nurses. For example, there have been debates over the introduction of a 30-year age bar for female nurses migrating abroad to certain countries, particularly those in the Middle-east.8 The INC faces several challenges in regulating the nursing profession, including its ability to steer policy. Limited political influence, perhaps because of the historically low status of the nursing profession and perhaps even the role of gender, particularly within the context of patriarchal societies, inhibits the ability of nurses to influence health policy, and to lobby for the required professional and academic developments (Gill 2018; Walton-Roberts 2012). In general, low salaries and poor working conditions, especially in the private hospital sector where Government mandated pay increases for nurses have not been extended (Sharma 2019), and limited opportunities for continued professional development are some of the reasons nurses seek employment opportunities overseas (Walton-Roberts et al. 2017). Moreover, private nurse education institutes cost more than government ones, and these costs eventually become an important migration driver, as domestic salaries are low. International migration is a significant reason for entering the nursing

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profession, with research indicating upward of 60% of nursing students express their intention for migration as one reason for entering the profession (Walton-Roberts 2012). Indeed, a nursing education is globally seen as a passport, in terms of the potential it offers for international migration (Connell 2009). The exorbitant fees and risk of fraud and exploitation involved with migration from India to the GCC does not deter potential migrants from pursuing these opportunities (Varghese 2020). The COVID-19 pandemic has added new dimensions to the aspirations of Indian nurses to migrate abroad (Khadria and Tokas 2022).9 South India is the source of a significant share of nurses who work overseas, as well as within India (Nair 2007). One reason for this has been the tradition of human service propagated with the spread of Christianity in the Southern states, particularly Kerala, by the Christian missionaries through the Indian colonisation (Khadria 2007). The GCC is an important destination for Indian nurses. For example, 57% of nurses migrating from the Indian state of Kerala resided in Gulf countries in 2016, with Saudi Arabia the top destination (WHO 2017). While India has developed mechanisms and sought agreements to protect the rights of Indian workers in UAE, evidence of abuse and exploitation (especially of irregular migrants not covered under formal government registration systems) indicates that more concerted efforts are needed (Chanda and Gupta 2018). The latest among these is the scam involving anywhere from 300 to 500 Indian nurses becoming stranded in the UAE (Babu 2021; Gokulan 2021). These nurses were reported to have been duped by a recruiting agency with the promise of jobs and were found stranded on March 10, 2021 without food and pay.10 UAE health care providers offered jobs to all, and health care groups were able to absorb 9 male and 81 female nurses to work as patient support staff or service assistants. They were also assisted in writing the examination to obtain the relevant health care licence to practice as registered nurses in the UAE. Speaking at length to Gulf News, some of the nurses narrated how impressed they were by the UAE’s generosity, which allowed them to provide financial support to their families back home.11 A paediatric nurse from Thrissur, Kerala, who had about three years’ experience, shared her sense of contentment with the work she was engaged for in a UAE hospital, noting the attractive salary, and the assistance they provided her in preparation for the necessary Department of Health (DOH) licence.12 A medical and surgical ward nurse with over seven years’ experience told the same Gulf News reporter of her less than satisfactory experiences, mentioning that she had paid Rs 200,000 to a recruitment agency and was unable to get any of it refunded.13 The media reporting and public response to this event resulted in an investigation by the Ministry of External Affairs (MEA) in New Delhi and the Indian consulate in Dubai, which found evidence that Indian recruitment agencies may have been involved.14 One of the nurses from Kerala stranded in Sharjah told India Today that she had been promised positions at various COVID-19 vaccination and

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testing centres and in private and government hospitals in UAE. Indian authorities have urged the victims to file formal complaints so they could approach Emirati authorities, but few in this case appear to have registered a complaint, mainly out of fear of deportation. Indian and UAE authorities stated that they repeatedly urged people seeking jobs in the Emirates to go through proper channels and only engage authorised recruitment agencies, but they argue that many still prefer to engage in migration outside of formal channels (Gaur 2019). One approach to formalise the scope of migration between countries and enhance migrant protection is through formal bilateral agreements, including those focused specifically on migrant labour.

Bilateral agreements in health worker mobility vis-à-vis multilateral norms How can India–UAE collaboration help the two countries to mutually develop their healthcare sector, and strengthen nurses and the nursing profession? Bilaterally, in 2018, the Federation of Indian Chambers of Commerce and Industry (FICCI) in collaboration with National Skill Development Corporation hosted a skill mapping conference in Dubai (NSDC 2018).15 Organised by the Ministry of Human Resources and Emiratisation (MoHRE), Government of UAE, the Ministry of Skill Development and Entrepreneurship (MSDE), the MEA, and Government of India (GoI), its objective was to assess the workforce demand in the UAE and supply by India. It also discussed the Indian government’s plans of investing in skills in key sectors and mobility pathways for skilled workers. As quoted in FICCI (2018), in this conference, the Secretary General of the UAE’s Federation of Chambers of Commerce and Industry, Mr Mohammed Bin Salem, stated that FICCI was focused on skill mix and harmonisation to promote UAE investment in India and promote mutual recognition of skills. The Ambassador of India to the UAE reinforced the importance of such interaction to upskill Indian migrant workers and noted how e-migrate systems and minimum wages could protect migrant workers. Clearly, government officials recognise the value that labour migration brings to the two nations, but despite the significance of nurses in the migrant labour flows between India and the UAE, their lack of specific inclusion in the limited labour agreements between the two nations is notable. The influence of MOUs and bilateral agreements in the domain of migrant labour has been identified as having limited influence in the case of India and the UAE, since they are often too broad to be of great consequence. Specific impacts are not always evaluated, and enforcement and reviews are often weak. Nevertheless, they are deemed to be of political and economic value since they express a desire and aspiration for negotiated agreements and provide a foundation for improvement (Wickramasekara 2012). The agreements between India and UAE are in the field of “manpower”, which, while applying to all workers, are mainly aimed at lower skilled workers who are managed through India’s “Emigration Clearance Required” (ECR) system. Agreements are also explicit about their

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application being under a temporary migration regime of contractual expatriate workers who will return home to India, not “migrant workers” (Wickramasekara 2012). MOUs between Government of India and Government of UAE for cooperation in the field of manpower have developed over several years, beginning as early as December 2006. A Joint Committee on Manpower issues – Second Joint Committee Meeting was held in New Delhi in September 2011, with the first meeting held in Dubai in May, 2007.16 On April 4, 2012, a protocol was signed to streamline the admission of Indian contract workers through a registration-cum-validation system of an electronic contract. Subsequently, on September 13, 2014, a conference was organised by the Embassy of India in Abu Dhabi to bring together various State government representatives from India and the Indian community in UAE.17 More recently, negotiations regarding migrant labour between India and the UAE have focused on India’s interest in promoting and advancing its integrated digital platform, Emigrate, for controlling international labour migration. This platform is a web-based portal that connects the recruitment and deployment of Indian workers. Since 2015, the portal has included Indian nurses heading to certain countries, including the UAE. In India, a Joint Working Group (JWG) on Skill Development was developed under the provisions of the MOUs for Cooperation in Skill Development and Recognition of Qualifications signed with UAE in February 2016. The JWG held its first meeting in New Delhi on April 29, 2016, which was co-chaired by Secretary, Ministry of Skill Development and Entrepreneurship (MSDE), India and Director General of the National Qualifications Authority, UAE. Subsequently, a meeting was held on January 31, 2018, at UAE Ministry of Human Resources and Emiratisation in Dubai, where bilateral issues regarding manpower and labour were discussed. Table 2.1 provides details on the various agreements between UAE and India regarding “manpower” and labour mobility. The MoUs listed in Table 2.2 focus on “manpower” in general, but there is no specific mention of nursing in the available information provided, or in reports on bilateral migrant labour skills development (Suri and Kumar 2020). References to mutual recognition of credentials, recognition of prior work and skills and comments on recognition of Indian training institutions would all be highly applicable to the case of Indian nurses working in the UAE, but there is no mention of the nursing occupation specifically in these “manpower” agreements. The only place where the nursing occupation is mentioned specifically is in media commentary on the cooperation in prevention and combating of human trafficking (Thomson Reuters Foundation 2016). Certainly, this could be seen to reflect the tendency to see nursing through the lens of vulnerability due to its gendered composition, rather than as an in-demand profession that required codified training and was highly skilled. The lack of formal agreements between the two countries focused on the mutual recognition and training of nurses that is needed considering the significant flows of Indian trained nurses working in the UAE. There appears

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Table 2.1 MOUs between UAE and India regarding “manpower” and migrant labour issues Date

Name

Details

Source

2011 (first signed in 2006)

Memorandum of Understanding between the Government of the UAE and GoI in the field of Manpower

International Labour Organization (2011)

2016

Letter of Intent between the Ministry of Skill Development and Entrepreneurship and National Qualifications Authority of UAE on Cooperation for Skill Development and Recognition of Qualifications MoU between the Government of the Republic of India and the Government of UAE on cooperation in prevention and combating of human trafficking

The key focus of this Memorandum is on enhancing the institutional partnership between the two countries in the field of workforce and improving administration of the Indian workers’ contracted employment cycles in the UAE. Intention to cooperate on mutual recognition of qualifications, prior work and skills, and facilitate accreditation of training centres (public and private) in India.

This MoU aims to enhance bilateral cooperation on the issue of prevention, rescue, recovery and repatriation related to human trafficking, especially of women and children expeditiously. To cooperate in the field of manpower, India and the UAE signed an MoU that aims to institutionalise the collaborative administration of contractual employment of Indian workers in the Gulf country.

Embassy of India, (nd) “Bilateral Agreements, MOUs Signed between India and UAE”

2017

2018

MoU on Manpower to streamline the process of manpower sourcing, benefit Indian workers and UAE employers alike, and foster the exchange of information between the two countries.

Source: Table created by the authors

Government of India (2016)

Consulate General of India in Dubai (2018)

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to be no concerted effort on the part of the Indian government to upgrade the skills of nurses to maximise their professional experiences overseas, their income and occupational status. The GoI has engaged in state regulation of the recruiting agencies permitted to engage in the overseas deployment of nurses, but this effectively downgrades the status of nursing to enable its management as part of the lower skilled migration management system. In 2015, the government added nurses to the Emigration Check Required (ECR) category (Walton-Roberts et al. 2022; Khadria 2020). The GoI claimed that this system would verify jobs and reduce exploitation.18 However, there are concerns that such regulation reveals a form of gendered migration governance that distorts the migration process and fails to protect all nurse migrants, even as it permits more intense state control of migration or allows for what has been termed a form of “controlled informality” (Varghese 2020). Moreover, after the imposition of these regulations, the monetary and bureaucratic cost of migration increased for candidates since applications can only be processed through agencies located in 6 of India’s 28 states (Walton-Roberts et al. 2022). Migrant nurses have also been affected by regulatory changes made by the UAE in 2019 that would have been forestalled by the implementation of recent “manpower MOUs” on mutual recognition of qualifications and recognition of Indian training institutes. In 2019, the UAE made a bachelor’s degree in nursing the required educational qualification for all nurses working in government hospitals. The UAE’s decisions placed Indian nurses with diplomas at risk of losing their jobs. Indian nurses with post basic certificates (training that effectively makes a diploma equivalent to the Bachelors), were only acceptable if they had been completed in Kerala, since that is the only nursing council recognised by the UAE’s Ministry of Education (Hindustan Times 2019a). These contradictory policy moves by the two countries reveal a significant gap in how each country manages the mobility of nursing labour. In effect, the UAE was making changes that demand nurses to be highly educated and skilled, while the GoI has been relegating nurses to the lower skilled migrant labour ECR management system. When it comes to actual recognition of credentials in terms of the assessment of skills and mechanisms of ‘quality control’ by the UAE, rather than use the bi-national or bi-lateral relationship with India, the UAE Ministry of Health turned to Kerala; the relationship of importance was focused on the sub-national level. The UAE turned directly to Kerala, the state that provides most nurses to UAE, rather than to the central government for credential recognition issues. The Indian central government, in turn, rather than launching a nation-wide agenda of professionalisation and upgrading of nurse education, forces nurses into a centrally managed migration system aimed at protecting lower skilled labour migrants. The dissonance between the rhetoric of the MoUs on “manpower” and the experiences of Indian nurses who migrate to the UAE is surprising and puzzling. This is doubly so when we consider the increased importance of this occupational group in view of the COVID-19 pandemic.

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COVID-19 pandemic responses: repatriation and return The COVID-19 global pandemic resulted in immense disruption for migrant workers as borders were closed and workers repatriated, including Indian workers in the UAE. Throughout the pandemic, India provided essential goods to the UAE, and special flights facilitating the return of doctors and nurses to the UAE were emblematic of the two countries’ close relationship. Indians were also among 212 doctors granted a 10 year “golden residency” visa by UAE in recognition of their service to frontline medical care during the pandemic, and 88 Indian health care professionals, including 60 critical care nurses, travelled to the UAE in May 2020 to support efforts against COVID-19 (Hindustan Times 2019b). The UAE also sent medical equipment to India to assist in treating COVID-19 patients and committed “all resources” to support India’s COVID-19 efforts (Sankar and Kumar 2021). Other countries contributed assistance to India to fight COVID-19 during early 2021, with some concern expressed about whether the resources were reaching those who needed them (Yeung et al. 2021). In October 2020, The UAE–India Healthcare Conference promoted deeper collaboration and partnership between the two countries to support the development of Indian healthcare manufacturing companies, with the UAE providing financial incentives. The UAE Ambassador to India noted how the global pandemic had created an opportunity to enhance diplomacy in the healthcare field (Orissa Diary.com 2021). The development of deeper healthcare partnerships in the wake of the pandemic builds upon a more recent history of exchanges in health capacity, in terms of both Indian healthcare investment and healthcare worker migration, particularly nurses. More generally, the global pandemic has invigorated the international migration of nurses. Recent reports indicate that overseas demand for Indian trained nurses has increased 50% over pre-COVID-19 numbers, and this includes those destined for the UAE (Chandna 2021). The state of Kerala has intimated that state investment could include a focus on health care worker training to meet international demands and thereby boost the international remittances migrants contribute to the state economy (Sunil 2020).

Conclusion Friendly relations between countries can help both countries tide over troubled times. Similarly, troubled times can help deepen friendly relations between two or more countries. We have examined the deepening relations between India and the UAE over the past decade in terms of health sector investment and labour migration in general. The size of the Indian diasporic population in the UAE is impressive, and includes significant numbers of India educated nurses, especially from Kerala. Indian health care companies are prominent in terms of current investment relations between the two nations, and lauded for contributing to future growth, innovation and

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enhancing mutual benefits for both nations. A core element of the exchange between these two nations is the movement of India-educated nurses, but the value of this resource to both nations seems curiously underplayed. A paradoxical lack of bilateral agreement language specifically targeted to the skills development and mobility of nurses is apparent. While the two nations discuss mutual recognition of education credentials, the lack of attention to nursing education by the Indian government is hampering the actual processes of migration and workplace integration for Indian nurses in the UAE, leaving them less empowered to assert their labour rights and protections. While the UAE is demanding an enhanced level of nursing education, the Indian government has focused its attention on managing nurses’ mobility by downgrading them to low skilled ECR-managed labour. The UAE has recognised the nursing education provided at the sub-national state level, signalling their interest in working with Kerala-based institutions for the upgrading of the diploma holding nurses. The reasons for the persisting lack of focus on upgrading and improving the status of nursing nationally connects to the traditionally downgraded status of the profession within the Indian hierarchical socio-economic system. There is an urgent need for meeting the necessary condition regarding state obligations and rights about the education, deployment, and utilisation of India’s migrant nurses in the UAE, but the sufficient condition for change that must be met in time is that the status of nursing in India must improve, alongside better recognition overseas. This is a policy agenda the Indian government need to put together in the post-COVID-19 phase, and one that aligns with the its interests in labour mobility, enhanced professional education, and labour deployment to maximise the potential for migrant healthcare professionals and the states in expanding healthcare services and improving their citizens’ wellbeing, at home and abroad.

Notes 1 Thanks to Harshul Mehta at Wilfrid Laurier University who provided valuable research assistance. 2 It is important to note that the nurse migration from India to the Middle East may remain stable or rise even when the adverse effect of COVID-19 on female mobility is higher than on overall mobility and the growth in female migrant stocks might be negative in some sub-regions of Asia in 2021 (Khadria and Mishra 2021, pp.17–18). 3 In 2010, the Sixty-third World Health Assembly adopted the WHO Global Code of Practice on the International Recruitment of Health Personnel. Its article 3.5 said: International recruitment of health personnel should be conducted in accordance with the principles of transparency, fairness and promotion of sustainability of health systems in developing countries. Member States, in conformity with national legislation and applicable international legal instruments to which they are a party, should promote and respect fair labour practices for all health personnel. All aspects of the employment and treatment of migrant health personnel should be without unlawful distinction of any kind. https://www.who.int/hrh/migration/code/WHO_global_code_of_practice_EN.pdf. (Accessed on 13 October 2021)

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4 Medical tourism implies travelling to another country across an international border for taking medical treatment, usually at a substantially lower cost than in the home country. It is a subset of Health Tourism, a term that covers a wide field ranging from preventive and health-conducive treatment to rehabilitation and curative forms of medical treatment. 5 https://www.mobihealthnews.com/news/emea/middle-east-s-aster-dm-healthcareannounces-partnership-roche-diagnostics. Mobile Health News. (Accessed 29 October 2021). 6 http://www.indiannursingcouncil.org/ (Accessed 29 October 2021). 7 https://www.indiannursingcouncil.org/uploads/pdf/ 161416628418349698776036390c4820d.pdf. Apparently, the UAE also does the same through its Nursing and Midwifery Council. See: http://www.uaenmc.gov.ae/ en/About%20Us/OurMission.aspx; http://www.uaenmc.gov.ae/en/Nursing%20And %20Midwifery%20Education/Overview.aspx (accessed on 1 December 2021). 8 https://mea.gov.in/Images/attach/GuidelinesEmigrationClearanceSystem_new.pdf (clause xiv, page 6 of Guidelines mentions the role of National Commission for Women) (accessed on 1 December 2021). 9 See, Khadria (2007) to compare the changes in perspectives and aspirations of different generations of nurses across the two decades. 10 Gulf News, 21 May 2021 https://gulfnews.com/uae/health/90-stranded-indian-nursesin-uae-from-kerala-land-jobs-with-top-abu-dhabi-health-care-firm-1.79430499 (Accessed 28 October, 2021). 11 Gulf News, 21 May 2021 https://gulfnews.com/uae/health/90-stranded-indian-nursesin-uae-from-kerala-land-jobs-with-top-abu-dhabi-health-care-firm-1.79430499 (Accessed on 6 June 2021). 12 “90 Stranded Indian Nurses in UAE from Kerala Land Jobs with Top Abu Dhabi Health-Care Firm”, Doctor Soon, 25 May 2021 https://doctorsoon.com/news/ details/393/90-stranded-Indian-nurses-in-UAE-from-Kerala-land-jobs-with-top-AbuDhabi-health-care-firm. (Accessed 26 October 2021). 13 Economic Times, “UAE Firm Offers Job to 90 Indian Nurses Stranded Due to Job Scam”, 24 May 2021 https://economictimes.indiatimes.com/news/international/ uae/uae-firm-offers-job-to-90-indian-nurses-stranded-due-to-job-scam/articleshow/ 82919104.cms?from=mdr (Accessed 26 October 2021). 14 India Today (21 May 2021) https://www.indiatoday.in/india/story/mea-investigatesas-uae-fake-job-scam-dupes-kerala-nurses-1805204-2021-05-21 (Accessed on 6 June 2021). 15 https://www.msde.gov.in/sites/default/files/2019-09/Strengthening%20partnership% 20between%20India%20and%20the%20UAE.pdf (Accessed 26 October 2021). 16 https://www.indembassyuae.gov.in/political-relation.php (Accessed 28 October 2021). 17 See http://www.mea.gov.in/Portal/ForeignRelation/UAE_Jan_2015.pdf (Accessed 28 October 2021). 18 One reason for this has been to ensure state protection for nurses under the Protectorate of Emigration. They require an Emigration Clearance certificate before departing India for accepting jobs in certain countries, if they do not fulfil certain conditions, like not being educated beyond 10th standard, or not being an income-tax payer by virtue of having low incomes, and hence belonging to deprived sections of the population in India.

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References Al-Talabani, H., Kilic, H., Ozturen, A. and Qasim, S.O. (2019) Advancing medical tourism in the United Arab Emirates: Toward a sustainable health care system, Sustainability, 11 (1), p. 230. Anand, S. and Fan, V. (2016) The health workforce in India. WHO. Available at: https://apps.who.int/iris/bitstream/handle/10665/250369/9789241510523-eng.pdf ? sequence=1&isAllowed=y (Accessed 7 November 2022). Babu, R. (2021) “500 nurses from Kerala duped, stranded in UAE”, Hindustan Times, 17 May. Available at: https://www.hindustantimes.com/india-news/500-nurses-fromkerala-duped-stranded-in-uae-101621191368903.html (Accessed 6 December 2021). Calabrese, J. (2020) “India-Gulf migration: A testing time’. Middle East Institute. 14 April. Available at: https://www.mei.edu/publications/india-gulf-migration-testingtime#_edn5, (Accessed 6 December 2021). Chanda, R. and Gupta, P. (2018) “Indian migration to the Gulf: Overview of trends and policy initiatives by India”, in P. Fargues and N.M. Shah (eds.), Migration to the Gulf: Policies in Sending and Receiving Countries. Jeddah, Geneva, Cambridge: European University Institute, Gulf Research Center, pp. 177–197. Available at: https://gulfmigration.org/publications/book_grm2017/ (Accessed 23 May 2021). Chandna, H. (2021) “Ireland to Malta, UAE to Belgium-all want Indian nurses, offer better pay and perks”, The Print. 3 March. Available at: https://theprint.in/health/ ireland-to-malta-uae-to-belgium-all-want-indian-nurses-offer-better-pay-and-perks/ 612606/ (Accessed 6 July 2021). Connell, J. (2009) The Global Health Care Chain, From the Pacific to the World. New York: Routledge. Consulate General of India in Dubai (2018) “Joint Statement India-UAE Joint Statement during State Visit of the Prime Minister of India to UAE” (10–11 February, 2018). Available at: https://www.cgidubai.gov.in/page/joint-statement/ (Accessed 28 October 2021). Embassy of India (n.d.) “Bilateral Agreements, MOUs signed between India and UAE”, Abu Dhabi UAE. Available at: https://www.indembassyuae.gov.in/bilateralagreement.php (Accessed 28 October 2021). Embassy of India (n.d.) “Economic and Commercial Relations”, Abu Dhabi UAE. Available at: https://www.indembassyuae.gov.in/bilateral-eco-com-relation.php#:~: text=India%2DUAE%20trade%2C%20valued%20at,for%20the%20year%202019% 2D20 (Accessed 23 May 2021). FICCI – Federation of Indian Chambers of Commerce and Industry (2018) “Partnership to meet UAE’s skill demands and ensure Indian workers get due skill-premium”, FICCI. Available at: https://ficci.in/pressrelease-page.asp?nid=3088 (Accessed 6 December 2021). Gaur, S. (2019) “Policies for protection of Indian migrant workers in Middle East”, in India’s Low-Skilled Migration to the Middle East, pp. 125–163, Singapore: Palgrave Macmillan. Gill, R. (2018) “Gender stereotypes: A history of nursing in India”, Social Action, 68, pp. 43–55. Gokulan, D. (2021) “Fake job offers in UAE leave over 300 Indian nurses stranded”, Khaleej Times. 18 May. Available at: https://www.khaleejtimes.com/coronavirus/ fake-job-offers-in-uae-leave-over-300-indian-nurses-stranded (Accessed 6 December 2021).

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Government of India (2016) Letter of Intent and Memorandum of Understanding signed with Ministry of Skill Development and Entrepreneurship of India and the United Arab Emirates for cooperation in skill development and recognition of qualifications, Ministry of Skill Development and Entrepreneurship, Press Information Bureau. Available at: https://pib.gov.in/newsite/PrintRelease.aspx?relid=138292 (Accessed 6 December 2021). Hindustan Times (2019a) “Indian nurses in UAE may lose jobs over new educational requirement”, IBy Indo Asian News Service. 15 October. Available at: https://widgets. hindustantimes.com/education/indian-nurses-in-uae-may-lose-jobs-over-new-educational-requirement/story-zWtB9CZE6uvEJvWTbB7AuK.html (Accessed 22 May 2021). Hindustan Times (2019b) “India permits 835 healthcare professionals to travel to Saudi Arabia for fight against Covid-19”, Hindustan Times. 14 May. Available at: https://www.hindustantimes.com/india-news/india-permits-835-healthcare-professionals-to-travel-to-saudi-arabia-for-fight-against-covid-19/story-nOCLSNcZNqBUsIbrOY4EWO.html (Accessed 22 May 2021). International Labour Organization (ILO) (2011) Memorandum of Understanding between the Government of the United Arab Emirates and the Government of India, ILO. Available at: https://www.ilo.org/global/topics/labour-migration/policyareas/measuring-impact/agreements/WCMS_379031/lang–en/index.htm (Accessed on 6 December 2021). Karan, A., Negandhi, H., Hussain, S., Zapata, T., Mairembam, D., De Graeve, H., Buchan, J. and Zodpey, S. (2021) “Size, composition and distribution of health workforce in India: Why, and where to invest?”, Human Resources for Health, 19 (39). Available at: https://human-resources-health.biomedcentral.com/articles/10.1186/ s12960-021-00575-2 (Accessed 5 June 2021). Khadria, B. (2007) “International nurse recruitment in India”, Health Services Research, Part II, Special Issue on International Migration of Nurses, 42 (3), pp. 1429–1436, Washington DC, Blackwell. Khadria, B. (2012) “Migration of health workers and health of international migrants: Framework for bridging some knowledge disjoints between brain drain and brawn drain”, International Journal of Public Policy, 8 (4/5/6), pp. 266–280. Khadria, B. (2020) “Between the “Hubs” and “Hinterlands” of migration in South Asia: The Bangladesh-India corridor”, International Journal of South Asian Studies, 10, pp. 1–10. Khadria, B. and Mishra, R. (2021) “Migration in Asia and its subregions: Data challenges and coping strategies for 2021”, Migration Policy Practice, 11 (1), pp. 14–20. Available at: https://publications.iom.int/system/files/pdf/mpp-44.pdf (Accessed on 6 December 2021). Khadria, B. and Tokas, S. (2022) “Aspirations of health professionals in India for migration abroad: a pre-Covid and Covid-time comparison of nurses”, in I.S. Rajan (ed.) India Migration Report 2022, India: Routledge. Nair, S. (2007) “Rethinking citizenship, community and rights: The case of nurses from Kerala in Delhi”, Indian Journal of Gender Studies, 14 (1), pp. 137–156. Naufal, G.S, Malit Jr, F.T., and Genc, I.H. (2016) “Contemporary Indian labour migration in the GCC region: Emerging challenges and opportunities, in I.S. Rajan (ed.), India Migration Report, India: Routledge, pp. 85–96.

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NHWA (2018) WHO National Health Workforce Accounts Data Portal, National Health Workforce Accounts. Available at: https://apps.who.int/gho/data/node.country. country-IND?lang=en (Accessed 06 December 2021). NSDC (2018), “Strengthening partnership between India and the UAE”, Government of India, National Skill Development Corporation. Available at: https://www.msde. gov.in/sites/default/files/2019-09/Strengthening%20partnership%20between%20India %20and%20the%20UAE.pdf (Accessed 6 December 2021). Orissa Diary.com (2021) “COVID-19 will mark an era of a paradigm shift in the realm of diplomacy with healthcare medical diplomacy taking the centre stage: Ambassador of India to UAE”, 20 October. Available at: https://orissadiary.com/ covid-19-will-mark-an-era-of-a-paradigm-shift-in-the-realm-of-diplomacy-with-healthcare-medical-diplomacy-taking-the-centre-stage-ambassador-of-india-to-uae/ (Accessed 28 October 2021). Osella, C and Osella, F. (2008) “Nuancing the migrant experience: perspectives from Kerala, South India”, in S. Koshy and R. Radhakrishnan (eds.), Transnational South Asians: The making of a neo‐diaspora, Delhi: Oxford University Press, pp. 146–178. Percot, M. (2006) “Indian nurses in the Gulf: Two generations of female migration”, South Asia Research, 26 (1), pp. 41–62. Sankar, A. and Kumar, A. (2021) “Covid-19: UAE offers all resources to support India’s fight”, Khaleej Times, 27 April. Available at: https://www.khaleejtimes.com/coronavirus-pandemic/covid-19-uae-offers-all-resources-to-support-indias-fight (Accessed 28 October 2021). Sharma, N.C. (2019) “₹20,000 minimum wage for nurses: what it means for corporate hospitals?”, Mint, 13 August. Available at: https://www.livemint.com/news/india/rs-20000-minimum-wage-for-nurses-what-it-means-for-corporate-hospitals-1565673899224. html (Accessed on 6 December 2021). Sunil, S. (2020) “Kerala to train, export nurses and paramedics to boost remittances after Covid”, The Print, 3 August. Available at: https://theprint.in/health/kerala-totrain-export-nurses-paramedics-to-boost-remittances-after-covid/473479/ (Accessed 6 July 2021). Suri, N. and Kumar, M. (2020) “Mapping skills: A roadmap for India and the UAE”, ORF Special Report No. 112, July 2020, Observer Research Foundation. Available at: https://skillsip.nsdcindia.org/sites/default/files/kps-document/skillmappinguaeandindia_2.pdf, (Accessed 6 December 2021). The Hindu (2018) “By 2030, India will need 2m doctors 6 m nurses”, IBy Indo Asian News Service, 7 March. Available at: https://www.thehindubusinessline.com/news/ by-2030-india-will-need-2-m-doctors-6-m-nurses/article22970727.ece (Accessed 6 June 2021). Thomson Reuters Foundation (2016) “India says will sign accord with UAE to stop human trafficking”, Reuters, 13 April. Available at: https://www.reuters.com/article/ india-trafficking-emirates-idINKCN0XA1EE (Accessed 6 December 2021). Varghese, V.J. (2020) “An industry of frauds? State policy, migration assemblages and nursing professionals from India”, in M. Baas (ed.) The Migration Industry in Asia, Singapore: Palgrave Pivot, pp. 109–133. Walton‐Roberts, M. (2012) “Contextualizing the global nursing care chain: International migration and the status of nursing in Kerala, India”, Global Networks, 12 (2), pp. 175–194.

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Walton-Roberts, M., Joseph, J. and Rajan, I.S. (2022) “Gendered mobility and multiscalar governance models: Exploring the case of nurse migration from South India to the Gulf”, in C. Ennis and N. Blarel (eds.), The South Asia to Gulf Migration Governance Complex, Bristol University Press. Walton-Roberts, M., Runnels, V., Rajan, I.S., Sood, A., Nair, S., Thomas, P., Packer, C., Labonte, R., Bourgeault, I., Tomblin-Murphy, G. and Mackenzie, A. (2017) “Causes, consequences and policy responses to the migration of health workers: Key findings from India”, Human Resources for Health, 15 (28) WHO – World Health Organization (2016) Global strategy on human resources for health: Workforce 2030, Geneva. Available at: https://www.who.int/hrh/resources/ global_strategy_workforce2030_14_print.pdf (Accessed 6 December 2021). WHO – World Health Organization (2017) “From brain drain to brain gain: migration of nursing and midwifery workforce in the state of Kerala”, WHO. Available at: https://www.studocu.com/row/document/kings-university-college/law-of-international-finance-1/migration-of-nursing-midwifery-in-kerala-who/11440933 (Accessed on 6 December 2021). Wickramasekara, P. (2012) “Something is better than nothing: Enhancing the protection of Indian migrant workers through bilateral agreements and memoranda of understanding”, Social Science Research Network. doi: http://dx.doi.org/10.2139/ ssrn.2032136. Yeung, J., Suri, M. and Gupta, S. (2021) “The world sent India millions in Covid aid. Why is it not reaching those who need it most?” India Cable News Network World, 5 May. Available at: https://www.cnn.com/2021/05/05/india/india-covid-foreign-aiddistribution-intl-hnk-dst/index.html (Accessed 28 October 2021).

3

Nursing shortage and mobility in China Current development and future possibilities Junhong Zhu, Huaping Liu and Yingchun Zeng

Introduction The average life expectancy of Chinese residents increased from 35 years in 1950 to 77 years in 2018. In this period, the maternal mortality rate decreased from 15 to 0.18 per 1,000 population, and the infant mortality rate decreased from 200 to 6.1 per 1,000 population (Qin 2019). The main factor contributing to these positive public health improvements are the Chinese government’s emphasis on promoting healthy lifestyles, improving full-life cycle health services, strengthening medical insurance policy, and building a healthy environment (The State Council of the People’s Republic of China 2017). Although there are positive developments in the current health level of Chinese residents, emerging health concerns over the last decade also need urgent attention. With accelerated industrialisation, urbanisation, environmental pollution, changing lifestyles, and an ageing population, the disease spectrum has also undergone significant changes. Long-term health conditions and non-communicable diseases, such as cardiovascular conditions, have become major public health concerns, causing 87% of China’s total deaths, and 70% of its total medical expenses or health expenditure. For example, stroke has now replaced cancer as the leading cause of death in China (China Daily 2019; Wu Y 2019). Currently, the Chinese government has placed a strong emphasis on the strengthening of healthcare services, and on investing in health workforce development, and nursing education in particular (State Council of the PRC 2017; Wu XJ 2019). Despite a rapid expansion of the nursing workforce in the labour market in China in the past decade (Figures 3.1–3.3), the total nursing workforce stock is still insufficient to meet the healthcare demand, especially in the community and elderly care sectors. An ageing population with a shrinking workforce pool, primarily due to the one-child policy in the past, is one of the key public health challenges. China has a population of more than 1.4 billion, and has more than 4.55 million registered nurses (Figure 3.1), representing one of the world’s largest reservoirs of nursing human resources (WHO 2020; Xiao et al. 2021). Further, China has a relatively younger nursing workforce in comparison to many affluent countries in the West (National Health Commission 2021). However, DOI: 10.4324/9781003218449-4

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Figure 3.1 Total number of RN (million) in China Source: Wu XJ (2019); National Health Commission (2020).

Figure 3.2 Nurses per 1,000 population in China Source: Wu XJ (2019); National Health Commission (2020).

the number of doctors and nurses per 1,000 population in China is not the lowest among Asian countries, such as India, the Philippines, Pakistan, and Japan, but it is still far behind those in some high-income countries, such as the USA, UK, Canada, and Sweden (WHO 2020). Nursing shortages are pronounced in rural China, which leads to huge physical, emotional and mental overloads for practicing nurses (Zhu et al.

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Figure 3.3 Ratio of nurses to physicians Source: Wu XJ (2019); National Health Commission (2020).

2014). Chinese nurses, who feel they have lost their hopes of pursuing an aspirational nursing career in the country, regard working or studying abroad as an alternative way of seeking personal freedom, and the professional recognition of being a nurse (Zhu et al. 2018). It is not surprising therefore, that China has been predicted as an important source of supply for the global nurse workforce (Kingma 2006). Within this context, this chapter aims to understand the current status of the Chinese nursing workforce, and emerging trends of immigration and emigration. This chapter is informed by a critical review of available literature, a number of studies carried out by the authors, and their long-term and ongoing engagement in the field of Chinese professional nursing education and employment.

Global nursing workforce shortages and the situation in China As early as 2006, the World Health Organization (WHO) warned all leaders of state about global nursing shortages, and the mal-distribution of nursing workforces, which would directly affect the quality of health services and patient safety. At that time, it was recommended that all countries, rich and poor alike, should develop a national nursing workforce plan (WHO 2006). Almost a decade and a half later, on World Health Day 2020, the WHO released a new report, State of the World’s Nursing 2020, again highlighting the global shortage of nurses, and calling for all governments to increase their investment in health professional education as one of the basic elements of preparing to tackle emerging global health challenges. The aims of these measures would serve not only to respond to new health challenges, such as emerging infectious diseases, but also would address the health challenges

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posed by climate change, an ageing population, and the increasing number of non-communicable diseases (WHO 2020). It is estimated that by 2030, the global demand for health workers will rise to 80 million, while supply is expected to reach only 65 million, resulting in a worldwide shortage of health workers (Liu et al. 2017). There would be a shortage of 800,000 nurses in the United States (US) alone, and 590,000 in Europe (Hudspeth 2013). An ageing nursing workforce, mainly in affluent economies, further complicates this situation. In the US, for example, the current average age of nurses is 47 years, with nearly 45% of registered nurses being over 50 years old (Letvak et al. 2013). In the United Kingdom (UK), 20% of registered nurses are over 50, and in Canada, 33% of nurses are over 50 years old (Keller and Burns 2010). Similarly, in New Zealand, 40% of nurses are over age 50 (Clendon and Walker 2013), while the average age of nurses in Denmark, France, Iceland, Norway, and Sweden is 41–45 years old (Letvak et al. 2013). In 2011, the average age of Australian nurses was 44.5 years, with the largest proportion of nurses aged 50–54 years (Graham et al. 2014). In contrast to this, in China, a significant proportion of the nursing workforce is much younger. For example, the large proportion of senior nurses in highincome countries, aged 55 years and older, accounts for only 4.5% of all registered nurses in China (National Health Commission 2021). The younger average age of China’s nursing workforce could be attributed in part to the country’s higher education expansion, as a consequence of its national higher education reforms in 2001 (Chinese Ministry of Health 2005). Due to the rise in life expectancy, a shrinking birthrate and an ageing workforce, some countries have increased the retirement age for men and women. For example, the Australian government has a plan to gradually shift the retirement age of nurses to 67 years, which would perhaps cause nurses to stay longer in the labour market, to address the nursing shortage, with the retirement age among nurses expected to increase to 70 years by 2035 (Duffield et al. 2015). Since 2018 China has been considering, and proposing, increasing the retirement age: namely that the retirement age for women should be raised by one year every three years, and the retirement age for men to be raised by one year every six years (China Daily 2019). This means that the retirement age for both men and women would be 65 in China by 2045. However, as yet, there are no feasible strategies to support this proposal of gradually delaying retirement in China. From the relatively smaller pool of senior and experienced nurses, a significant number of nurses are leaving the profession early. This in turn has caused a problem of nursing wastage in China, and has negatively impacted on the safety and quality of healthcare: an issue which has not been adequately addressed (Zhu 2012; Zhu et al. 2014; Zhu et al. 2018). Age discrimination is still common in the nursing workforce labour market (Zhu et al. 2014). There is an excessive policy focus on young and recent graduates, ignoring the importance of the effective human resource management of senior nurses. This is not conducive to the professional development of China’s nursing workforce (Xiao et al. 2021; Zhu et al. 2018).

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At the end of 2019, China had a total of 1,007,545 medical and health institutions, with more than 8.8 million hospital beds. The total number of healthcare professionals was 12.9 million, with 2.77 physicians and 3.18 nurses for every 1,000 people, respectively (National Health Commission 2020, 2021). In addition, there were 0.61 registered nurses per hospital bed in China, and 1.15 nurses for each physician in hospital (National Health Commission 2020). While the Chinese Ministry of Health set the standard at two nurses per physician in 2003 (Study Group (MOH) for Nursing Demand 2003), no hospital in China has reached this standard until the end of 2019. According to the World Health Statistics Overview, the most reasonable ratio of nurses to physicians is 3 to 1 (WHO 2018), but China has only 1.15 to 1, far lower than the WHO’s recommendation (see Table 3.1). Further, there is a huge disparity in health workforce distribution in China, depending on geographic region. As seen in Table 3.2, the density of nurses per 10,000 population in urban regions is far higher than that in the rural regions of China (National Health Commission 2020). Chinese nurses are more willing to work in the East of China than to work in the relatively undeveloped western part of the country, which has exacerbated the regional inequality in the healthcare services (Zhu 2012). As indicated in Figure 3.4, more than half of registered nurses work in tertiary hospitals in China, demonstrating just how different according to location the numbers of nurses are. While the number of nurses in China has increased significantly since 2010, ‘Healthy China 2030’ requires ‘15 minutes coverage of basic medical and Table 3.1 Chinese nursing workforce, 2010 and 2019

Total registered nurses (million) Nurses per 1,000 population Nurse-to-physician ratio Nurse-to-bed ratio

2010

2019

2.04 1.53 1.16:1 0.45:1

4.44 3.18 1.15:1 0.61:1

Source: National Medical Service and Quality Safety Report and Chinese Health Statistics Year Book 2020, in National Health Commission (2020)

Table 3.2 Registered Nurses in China, 2019 Area

Number

Density*

Urban Rural Total

2,603,260 1,841,787 4,445,047

52.2 19.9 31.8

*Density: per 10,000 population Source: National Health Commission 2021

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Figure 3.4. Number of registered nurses per 10,000 population in China by hospital types Source: National Health Commission (2021)

health services with the standard of 4.7 registered nurses per 1,000 permanent residents by the end of 2030’ (China State Council 2016). But large gaps in the number of nurses remain (China State Council 2016). Nursing workforce shortages and inequality in distribution are serious problems in China.

Discussion on the turnover and wastage of nursing workforce within China Lewis (2002) reminds us that the health workforce shortage is not merely about numbers, but is also a matter of how these numbers are most effectively deployed in the healthcare system. In China, a high rate (over 70%) of intention to leave the nursing profession has been reported in different areas nationwide (Sun et al. 2001; Ye et al. 2006; Lu et al. 2007). Several studies have examined Chinese nurses’ work satisfaction and found that about half of respondents were dissatisfied with their jobs (Lu et al. 2007; Li and Lambert 2008). However, although relatively high levels of dissatisfaction, and intention of leaving, were repeatedly found among Chinese nurses, there was only a relatively low rate of nurses who actually had the freedom to leave (Lu et al. 2007; Zhu et al. 2018). Compared with the efforts made in most western countries, Chinese hospital managers have not regarded the ratio of nurses to patients as a compulsory standard for the quality of healthcare based on a profit-driven system (Hsiao 2008; Zhu 2012; Zhu et al. 2014). The study demonstrated that nursing managers in Chinese tertiary hospitals still lack a comparable awareness of the issue, and the motivation to retain experienced nurses (Zhu et al. 2018). Further, there is a lack of official statistics to monitor the exact number of nurses who have actually left their posts in China, while nursing attrition has

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been paid attention in other Asian countries, such as India and Japan (GOI 2005; Nakata and Miyazaki 2008). In the past three decades, the nurse workforce policy in China has been affected by rapid economic, social-political, and educational changes in the healthcare system. These changes have greatly impacted nurses’ employment decisions. Although the nursing shortage in China is more serious than that in many other developed countries (MHPRC 2016; Zhu et al. 2018; Xiao et al. 2021), Chinese nurses continue to voluntarily leave nursing practice. This phenomenon has not been adequately realised by the policy-makers (Zhu 2012; Zhu et al. 2015). While the Chinese Nursing Association (CNA) leadership hopes the backlash of a national nursing shortage, and the subsequent negative impact on patient outcomes, will trigger Chinese healthcare reform, and improve the welfare of Chinese nurses (Xu 2003; Zhu 2012), Chinese nurses tend to keep their departures quiet and personal, which in turn results in ineffective communications between nurses and policy makers (Zhu 2012). The reasons for voluntary leaving include a mismatch of expectations, with the higher the degree of mismatch between individual and organizational expectations of nursing recognised by the nurses, and the greater the extent of imbalance of power the individual nurses perceived, the more likely it is that the nurses would plan to leave the powerless status of being a clinical nurse in the organisation. The more difficult it becomes for the nurses to achieve their individual expectations by exercising nursing autonomy in their nursing career, the more likely it is that they actually empower themselves to leave nursing practice (Zhu et al. 2015, p. 9). Further, nurses actively chose to stay in nursing when their individual and organisational expectations were well matched, and they were able to exercise nursing autonomy to achieve professional values and career ambitions (Zhu et al. 2014). Further, studies have found that the meaning of leaving nursing practice for Chinese nurses was different from the concept of “nursing turnover”, which has been widely reported and accepted in current literature (Hayes et al. 2012). The leavers expressed that they were usually aware that leaving their current posts was equivalent to leaving nursing, and was not a reversible process. Such evidence could partly explain why it was not feasible to see high mobility in the Chinese nursing workforce management system. The crucial point in Zhu’s (2012) study was that in order to pursue their personal freedom, individual nurses, with a higher perception of individual power, realise that they had to give up their hopeless fight for professional nursing status under organisational control, thus resulting in “voluntary leaving”. Those with a lower perception of individual power (or autonomy) did not have the freedom (or courage) to make a decision about leaving, and had to accept the powerless status of the current nursing workforce as normal, which resulted in “passive staying” (Zhu 2012). It was confirmed that nursing wastage was not only caused by nurses’ voluntarily leaving nursing practice, but also that it occurs when the nurses resorted to passive staying, through which they give up nursing autonomy without managerial and organizational support (Zhu et al. 2018).

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Lower grade hospitals (grade 1 and 2), located in less attractive rural areas, could not recruit sufficient numbers of nurses. Unfortunately, the level three urban hospitals have surplus candidates, and managers do not think that the knock-on effects of the nursing shortage nationwide should be their priority (Zhu et al. 2018). The Chinese Nurse Association has regularly suggested that Chinese hospitals recruit and retain as many nurses as possible to resolve the nursing shortage (MHPRC 2005, 2009). The main concern is that this situation has caused nurses’ morale to deteriorate. When compared with the higher rates in turnover in nurses in the West, where personnel management is flexible and relatively equal (Aiken et al. 2001; Lu et al. 2007), a relatively lower number of nurses actually leaving is seen in China (Sun et al. 2001; Ye et al. 2006). Chinese studies on nurses’ leaving have revealed that the actual rate of voluntary leaving depends on how nurses perceive their individual power/professional autonomy and how the meaning of leaving is shaped by the responses to their job dissatisfaction and stress (Zhu et al. 2018). Powerless nurses, those without professional autonomy, could not effectively influence policy. The meanings of leaving that the study participants perceive raises some fundamental questions, including how “voluntary leaving” and “passive staying” would differently impact an effective and sustainable supply and management of the nursing workforce. The case of Chinese nurses leaving nursing practice can offer a valuable lesson to understanding the relationships among the nurses’ voluntarily leaving, nursing wastages and nursing shortages, and to moving towards effective nursing workforce management (Zhu 2012). Scholars suggest that nursing wastages could be avoided if nurses have greater professional autonomy; then nurses’ contribution to the healthcare system can be valued better, and properly rewarded with managerial and organisational support (Zhu et al. 2018). The current literature on nursing shortages does not fully reflect the fact that nursing shortages might no longer be an issue for third-level hospitals in relatively affluent metropolitan areas in China (Zhu et al. 2018). Grade Three hospitals can select well-educated, and the best qualified, and indeed relatively younger, nursing graduates, for there are plenty of candidates on the waiting list for posts in these high-status hospitals (Zhu et al. 2015). When supply exceeds demand, a surplus occurs locally. The Chinese Grade Three hospital managers take the current surplus of nursing graduates for granted, based on the local oversupplied employment pool. Further, Anand et al. (2008) have reported that the imbalance of distribution of doctors and nurses in China occurs due to the inequality of social-economic development, and the limitations of the current healthcare system. This has also been confirmed in the Chinese health statistical database (MHPRC 2008, 2010). Furthermore, it is worth noting that the Chinese standard staffing ratio, which was introduced in 1978, may not fully explain the current nursing shortage in China (MHPRC 1978). It is understandable that the low rate of nurses’ voluntarily leaving nursing practice could be temporary under the current Chinese organisational control,

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both in educational and clinical settings. However, nurses’ professional freedom will likely increase in the future due to demographical, financial, educational, and social changes that are taking place in the country. It could further be argued that if nurses are unable to exercise professional autonomy, to achieve essential nursing values, they are more likely to challenge the employers’ expectations, and pursue professional development, by leaving the nursing sector in China, or leaving the country to find nursing jobs abroad. Therefore, it is predictable, if the policy makers and the hospital managers still take organisational control for granted without effective intervention, the rate of voluntary leaving may dramatically increase (Zhu et al. 2014). The study by Zhu (2012) highlighted that wastage was arguably the most pressing and potentially serious challenge for the Chinese nursing workforce management. The study suggested that while meeting the target number of registered nurses was the main concern, nursing educational bodies, clinical institutions and the governments have avoided discussing the urgent issue of nursing wastage. This demonstrated a lack of comprehensive understanding of the causes of relative surplus, and the consequences of wastage as an important issue related to the nursing shortage. To avoid nursing wastage, retention strategies should be considered, by supporting nurses’ active staying in a nursing career, rather than trap them into “passive staying” for life under organisational control. Studies have suggested that nurses who leave nursing practice have a wealth of experience that should be used to inform the decisions of the policy makers, in order to address the key issues with nursing workforce issues, such as outflow and retention (Buchan and Sochalski 2004; Zhu 2012). It is essential for nursing managers to retain the nurses who hold a strong perception of professional autonomy, and wish to be respected for their professional value and contribution. Nurses are a great asset of any healthcare system, and are the backbone of Chinese nursing development by their active staying.

Chinese nurses working abroad and shortages at home Those Chinese nurses who have lost their hopes of pursuing aspirational nursing careers in top Level Three Chinese hospitals consider working or studying abroad as an alternative way of seeking value and professional advancement (Zhou et al. 2011; Zhu 2012). In 2001 the International Council of Nurses (ICN) published ethical guidelines for international nurse recruitment, which not only recognise the right of an individual nurse to migrate, but also acknowledge the possible adverse effects that migration may have on healthcare quality in source countries (see Zhou et al. 2011; Zhou 2012). Compared to some countries that are opposed to the migration of their nurses, China is perceived to be a more ethical source for recruitment (Xu 2003; Fang 2007). Since the Chinese government and the Chinese Nursing Association openly supported the outmigration of Chinese nurses (Xu Y. 2004; Xu and Zhang 2005), China was

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viewed as an increasingly important supplier of nursing in the context of the widening gap between the global demand for and supply of nurses in the future (Kingma 2006; Fang, 2007; Pittman et al. 2007; Xu, 2003; Xu and Zhang 2005). However, data revealing the scale of nurse outmigration from China are scarce. Two studies indicated several barriers for Chinese nurses working abroad (Xu 2006; Zhou et al. 2011). The study findings suggested that, many nurses were discontented with the working situation in China. For Chinese nurses, international migration was a route to fulfilling their professional aspirations and expectations. These findings echo Zhu’s study (2012) of Chinese nurses leaving nursing practice in China. However, it is often the case that many migrant nurses are unaware of the challenges they may encounter abroad. Due to the differences in nursing curricula, language, and cultural issues between China and the recipient countries (for instance, the USA and Australia), Chinese nurses experience difficulties in obtaining recognition of their nursing qualification, and in obtaining professional licences. The study participants had mixed feelings about immigration (Xu 2006; Zhou et al. 2011; Zhu 2012). The desire for a better life went together with the ubiquitous experience of discontentment, while the dream remained unfulfilled when they were working abroad. Study findings highlight that the majority of Chinese nurses who chose to study or work abroad belonged to a relatively privileged population group with a stable job, income, and welfare in China before they decided to leave nursing practice in China (Zhou et al. 2011). The participants were disappointed to find out that the reality in the destination countries did not always match their initial expectations. There was a desire to go back home, however return was hard. There was a lack of viable professional alternatives at home for the Chinese migrant nurses, with returning deemed as seeming impossible. Studies on Chinese nurse migration highlight that, although the immigration process was perceived by the participants as challenging and stressful, there was also an acknowledgment of benefits following their move (Xu 2006; Zhou et al. 2011). The participants generally perceived that the working conditions for nurses in Australia and the USA were superior to those in China. One of the advantages of working in Australia and the USA was that the participants gained a sense of professional autonomy in their work. Other benefits included better remuneration and better welfare (Xu 2006; Zhou et al. 2011). In addition, nurses enjoyed a more flexible work schedule, and more professional autonomy in care delivery, in Australia and the USA. Chinese migrant nurses were converting differences into learning opportunities, which accorded with the interests of host societies and nurses themselves (Zhou et al. 2011). Currently, there is a shortage of Nursing Faculties offering Doctoral degrees in Chinese nursing universities. Therefore, some Chinese nurses preferred to move abroad to continue their studies, rather than to gain more work experience. For being awarded international degrees would provide them with an opportunity to return to their home country as a nursing educator or a nursing researcher. Chinese nurses who are fluent in English, who were

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working abroad and gained formal research training, are highly valued in Chinese universities. The high demand for nursing faculty members with an international education is also due to a recent expansion of international nursing education within China.

Key factors affecting international nurse migration in China Immigration policy The international recruitment and flow of nurses has become an important phenomenon in global nursing human resource management (Buchan 2006). The international migration of Chinese nurses began in 1978, when a market economy policy was adopted, to initiate China’s economic reform. Since the 1990s, the Chinese government began to organise English-speaking nurse groups for temporary work in Singapore, Japan, Germany and Saudi Arabia (Xu 1997). The contract was based on bilateral agreements and usually lasted for 2–3 years. According to the contract arranged by the government, a large number of Chinese nurses went to work in these countries every year. The Chinese government would charge 10–15% of their annual salary as a handling fee. After the contract expired, the nurse would return to the original workplace (Xu 1997). Furthermore, with China’s rapid transition to a market economy, nursing migration was driven by international high-demand markets. Consequently, the number of Chinese nurses working in Australia and the UK has increased since 2002, especially after these countries relaxed their immigration requirements. Most of these nurses’ contracts were arranged by private companies rather than government agencies, and nurses needed to pay a sum of money to the company for immigration services (Fang 2007). With regards to Chinese nurses working in the US, after a failed attempt in the early 1990s, the American Nursing Association established a Commission on Graduates of Foreign Nursing Schools (CGFNS) examination centre in Beijing in November 2003, with support from the Chinese government and the Chinese Nursing Association (CNA). Chinese nurses began to go to the US from 2003 (Xu Y. 2005). However, unlike some other major source countries, as the Philippines and India, the Chinese government and the CNA have not issued international nurse migration-related policies (Zhang 2013).

The impact of the Belt and Road Initiative The Belt and Road Initiative (BRI) is a strategy initiated by the Chinese government in 2013. It seeks to connect Southeast Asia, South Asia, Central Asia, Russia, the South Pacific, the Middle East, Eastern Africa, and Europe, via land and maritime networks, with the aim of improving regional integration, increasing trade and stimulating economic growth (European Bank for Reconstruction and Development 2021; Macaes 2019). The BRI draws

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inspiration from the concept of the Silk Road established during the Han Dynasty 2,000 years ago. The BRI comprises a 21st century Maritime Silk Road Economic Belt. The initiative defines five major priorities: policy coordination, infrastructure connectivity, unimpeded trade, financial integration, and connecting people. This has allowed many countries to gradually strengthen their trade and investment links with China. The Belt and Road 2019 International Nursing Conference was held together with the 110 Anniversary Ceremony of the Chinese Nursing Association (CNA) on 7 September 2019, in Beijing. The CNA signed Memoranda of understanding on nursing cooperation under The Belt and Road framework with 23 countries, including Cambodia, Cyprus, Ethiopia, Fiji, United Kingdom, Italy, Kenya, Lebanon, Malawi, Mongolia, Myanmar, Nepal, Northern Macedonia, Oman, the Philippines, Portugal, Russia, Serbia, South Africa, Sri Lanka, Thailand, Turkey and Zimbabwe. It aims to encourage dialogue, build consensus, and enhance cooperation in various aspects such as health systems, nursing policy, nursing education, personnel training, nursing practice and industrial development (CNA 2019). With the development of the cross-cultural nursing cooperation among the countries, international nursing education, academic exchange, and research collaboration have become increasingly important. The BRI framework has led to the reform of nursing training in China, and increasing international recruitment, in order to attract Chinese nursing scholars back to China after they complete their higher education, preferably a PhD study in nursing from America, UK, Canada, and also to attract European scholars (Shi 2017; Liu and Xu 2019).

BRICS Nursing Cooperation Platform BRICS is the acroynm for these nations: Brazil, Russia, India, China, and South Africa. These five nations comprise 40% of the global population, and health professionals must take responsibility for providing quality healthcare for that 40%. It was important for the five counties to establish a long-term collaboration. In 2016, the nursing associations of the BRICS nations signed a MoU of Nursing Cooperation, which was supported by the International Council of Nurses (ICN). The aim of this MoU was to establish a long-term nursing partnership among these nations, and to strengthen academic exchanges and sharing among their nursing societies. It sought to achieve mutual support, enhance strength, and to coordinate and promote the development of nursing among the five countries, and further, to drive global nursing development (Wang 2016).

International nursing students studying in China Under the BRI framework, and the BRICS cooperation agreement, the Chinese government encourages Chinese universities to initiate international medical and nursing education for overseas students, particularly for students

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from developing countries. According to the official website of the China Scholarship Council (CSC 2020), there are currently 66 universities in China that enroll foreign nursing students. The educational level includes non-academic degrees, Bachelor’s degrees, Master’s degrees, Doctoral degrees, and training for senior scholars. The length of schooling ranges from 0.5 to 5 years, and the courses are taught in English or Chinese. Among them, 36 schools provide students with non-academic qualifications, 55 schools with Bachelor’s degrees, 53 schools with Master’s degrees, with 19 schools offering Doctoral degrees. Witness the fact that in 2021, 32 Nepalese nursing students are studying in China at Master’s level, and one student at Doctoral level.1 Currently, the 66 universities provide international nursing and medical education programmes in English or Chinese for 327 foreign nursing students (118 Nodegree, 61 Bachelor, 104 Master, 44 Doctoral) and 1,158 medical students (416 No-degree, 154 Bachelor, 333 Master, 224 Doctoral, 7 General Scholar, 4 Senior Scholar). The enrolled students are entitled to a full Chinese Government scholarship, which includes tuition fees and living expenditure (CSC 2020). The students come mainly from Africa, India, Nepal, and other developing countries. To provide effective education for international students with multicultural and multilingual backgrounds, the medical and nursing faculty across the country have had to improve their academic standards. Bilingual communication, including fluency in speaking and academic writing in English, has became an important recruitment requirement for new nursing faculties. Therefore, many universities are struggling to attract more qualified young nursing faculty members with an international education at the Doctoral level. Evidently, there is a shortage of nursing faculty members in China, as illustrated earlier in this chapter. There is a lack of research evidence to evaluate the quality of nursing education for international students in China during their studies, as well as the usefulness of those courses, when they return back to their home countries after graduation. Nevertheless, the number of international nursing students has expanded in Chinese universities nationwide, which has contributed to nursing development internationally and, arguably, therefore offers an opportunity to improve the safety and quality of healthcare globally.

Nursing workforce management during the COVID-19 pandemic in China During the COVID-19 pandemic, the majority of countries had to face the challenge of maintaining the capacity of their existing health workforces. While most countries have called upon medical and nursing students, preregistered health professions, and asked retired or inactive health professionals to return to work in clinical practice (Williams et al. 2020), the Chinese government implemented a range of policy measures to encourage different provincial and county health authorities to send volunteer teams to serve in Wuhan, and other heavily affected areas, as acts of solidarity (State Council of PRC 2020).

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The shortage of health workers in China was quite severe during the peak of the COVID-19 surge. A total of 42,600 health workers including 28,600 nurses (68%), from across the country, went to Wuhan to take care of patients with COVID-19, regardless of the high risk of cross-infection (State Council of PRC 2020). Data from the National Health Commission of the People’s Republic of China revealed that more than 3,000 healthcare workers had been infected as of early March 2020, 62 of whom had died (Sun et al. 2021). Other infected health workers, meanwhile, became ill or entered self-isolation, which further limited the workforce capable of caring for patients. The death of those 62 health professionals may have resulted from inadequate precautions, and insufficient protection, in the early stages of the epidemic. As of 31 March 2020, none of the 42,600 healthcare workers, who went to Hubei Province to care for patients with COVID-19, were known to have been infected with the COVID-19. During this epidemic, further measures were promulgated to provide incentives to healthcare workers, and protect them in all aspects, including subsidies and allowances, work-related injury compensation, psychological health services, promotions, and daily needs support (Zhu et al. 2020). In addition to legal rights and policy protection, an elevated cultural shift in the social status and attitude toward doctors and nurses has been observed to reflect the health workers’ contributions, or sacrifices, for their country. Cities across China applaud them as “the most admirable people in the new era” (Sun et al. 2021). Both health professionals and patients have been understanding and supportive of one another in their fight against the virus. Doctors and nurses have received national recognition and, in turn, public respect for their pivotal role in halting the spread of the disease. The Chinese government also adopted innovative, specialised, and advanced systems, including empowered Fangcang (specialist, mobile and temporary hospitals designed to provide care for the COVID-19 patients) and Internet hospitals, as well as technologies such as online health codes, 5G, big data analysis, cloud computing, and artificial intelligence to strengthen healthcare. At a time of need, a large number of health professionals have had to change their previous means of interacting with the traditional healthcare system to provide instead an online healthcare service. The efficient use of these new methods helped China in managing the COVID-19 pandemic, as well as evoking ethical debate (Zhu et al. 2020). Nonetheless, not all healthcare workers have an adequate understanding of highly technical and online healthcare, which in turn has limited the effective employment of the nursing workforce to control the spread of infection. The challenges made all those concerned realise that online healthcare needed to be integrated into nursing and medical education, thus driving their significant inclusion in clinical practice in the future. After all fangcang hospitals in Wuhan had been closed on 10 March 2020, China sent volunteer nurses to help international communities in their fight against COVID-19. Chinese nurses have worked in different countries such as

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Italy, Serbia, and Iran to construct and operate fangcang shelter hospitals (State Council of PRC 2020).

Efforts made by the Chinese Nursing Association to support the international community in fighting the COVID-19 pandemic On 17 September 2020, the Chinese Nursing Association hosted the “One Belt, One Road” International Symposium on COVID-19 pandemic prevention and/or management. The CNA invited the president and vice president of six national nursing associations, including Italy, Russia, Burma, Portugal, Malaysia and the United Kingdom, to share and discuss their experience of caring for patients in the light of the COVID-19 pandemic. More than 160,000 participants attended the online conference. The second “One Belt, One Road” forum was sponsored by the CNA, and supported by the national nursing associations of Turkey, Lebanon, Serbia and Kenya on 2 December 2020. The aim of the online forum was to “fight the pandemic hand in hand and protecting health”. The live broadcast of the online seminar was watched by 80,000 nurses. The presidents of the four National Associations of nursing laid a foundation for in-depth and practical international nursing cooperation, based on sharing and discussing their experiences of COVID-19 infection treatment and pandemic prevention (CNA 2021). Further, the online discussion under the BRICS framework has provided a way to enhance mutual understanding among participating national nursing societies. The presidents promised that they would work together to strengthen exchanges and cooperation to address global health problems (CNA 2021). Following the promise of the CNA in 2020, an online training course, titled “Belt and Road, Nursing Responses to COVID-19 Outbreak and Public Health Emergencies”, was launched on 22 November 2021. The course was designed to enhance the capacity and management during the COVID-19 pandemic and public health emergency response. More than 130 senior nurses from 15 countries participated and successfully completed the training course.2 The course has been highly praised by students from all over the world (CNA 2021).

Conclusion In the past few decades, China has experienced rapid economic growth, social-political, and educational changes, including changes in its healthcare system. In order to resolve its nursing workforce shortage, the Chinese government has increased investment in nursing education. The number of registered nurses has dramatically increased, due to the expansion of education institutions in recent years. However, there is still a significant nursing shortage across the country, especially in rural areas. Meanwhile, the workforce pool (in general) is shrinking due to an increasing life expectancy and a declining birthrate in China.

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Ineffective nursing workforce management has resulted in a regrettable nursing wastage. Experienced nurses are voluntarily leaving nursing practice, or passively staying in a nursing career. Although Kingma (2006) predicted that China would become an important source of nursing workforces for developed nations, in recent years, the number of Chinese nurses working abroad has decreased due to the differences in nursing curricula, language, and culture between China and the nurse receiving countries. However, some Chinese nurses wish to pursue an academic degree abroad, or gain clinical experience via temporary exchange programmes in developed countries, in order to gain clinical qualifications as well as academic credentials. These nurses became the prime movers of nursing professional development after they return home, and have encouraged other nurses to go abroad for learning. The majority of these returnees with a PhD degree, have become involved in nursing education or nursing research in China. Foreigntrained Chinese nurses are valuable resources in the delivery of more effective education for foreign-born nursing students in China, and have become the backbone of Chinese higher education development. It is not clear whether the Chinese government and the Chinese Nursing Association have considered the international migration ethics framework, in order to increase the benefits all parties gain from nursing education and international nurse migration. There is a need to evaluate the quality of international nursing education in China, for its sustainable development, and to mutually benefit all the countries involved, based on bilateral government-to-government nursing migration agreements. Acknowledgements This study is supported by Zhejiang Provincial Health Department research grant (2021KY140), National Social Science Foundation (21ZDA101), Chinese government Fundamental Research Funds for the Central Universities.

Notes 1 Personal communication with Tara Pokhrel, the president of Nepal Nursing Association on 1 April 2021. 2 The key participants involved in this course were: The President of the Chinese Nursing Society, Wu, Xinjuan, Medical Director of International Committee of the Red Cross (ICRC) in East Asia, Luca Falqui, Vice President of the School of Public Health of Peking Union Medical College, Liu Yuanli, Nursing Consultant of Hong Kong Medical Administration, China, Jolene Mui, Deputy Director of the International Department of China Center for disease control Cao Xiaobin, Chairman of the Infection Management Committee of the Chinese Nursing Society, Cai Tabu, Vice Chairman of the Disaster Management Committee of the Chinese Nursing Society, Sheng Yu, Director of the Nursing Department of West China Hospital of Sichuan University, Jiang Yan, and many other Chinese and foreign experts on emergency plans and health strategies for public health emergencies, the quality and safety of nursing management, the mental health support of nurses during pandemic, the COVID-19 prevention and control experience, the care of severely ill patients, and other aspects of teaching.

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MHPRC – Ministry of Health of the People’s Republic of China (2016) ‘Chinese Nursing Development Project 2016–2020’. Available at: http://www.nhc.gov.cn/yzygj/s3593/ 201611/92b2e8f8cc644a899e9d0fd572aefef3.shtml (Accessed 28 August 2021). Nakata, Y. and Miyazaki, S. (2008) ‘Non-working nurses in Japan: Estimated size and its age-cohort characteristics’, Journal of Clinical Nursing, 17 (24), pp. 3306–3316. doi:10.1111/j.1365-2702.2008.02656.x. National Health Commission (2020) China Health Statistics Year Book 2019, Beijing: Peking Union Medical College Press. National Health Commission (2021) China Health Statistics Year Book 2020, Beijing: Peking Union Medical College Press. Pittman, P., Aiken, L.H. and Buchan, J. (2007) ‘International migration of nurses: Introduction’, Health Services Research, 42 (3p2), pp. 1275–1280. doi:10.1111/ j.1475-6773.2007.00713.x. Qin, G. (2019) ‘The quality of health care of Chinese women and children has improved significantly’, National Health Commission of the People’s Republic of China. Available at: http://www.nhc.gov.cn/xcs/s7847/201905/7490255c0dce462f85e54d7e2b6f17ee. shtml (Accessed 12 July 2020). Qu, G.Y., Jing, Y.Y and Tang, L.H. (2011) ‘Exploration and policy thinking of international nurses’ realization Approach’, International Journal of Nursing, 30 (4), pp. 581–584 (in Chinese). Shi, X.P. (2017) “On the Belt and Road” strategy in ethnic minority area of foreignrelated nursing curriculum system. Jilin, China: Yanbian University. State Council of the People’s Republic of China (2017) ‘China’s medium and long term plan for the prevention and treatment of chronic diseases (2017–2025)’. Available at: http://www.gov.cn/zhengce/content/2017-02/14/content_5167886.htm (Accessed 12 July 2020). State Council of the PRC (2020) ‘Press conference of joint prevention and control mechanism of the state council’, Beijing. Study Group (MOH) for Nursing Demand (2003) “Study of Chinese Nursing Human Resource Status and Suggestions on Strengthening Training Programs for Nursing Professionals in Short”. [15 March 2005]. Ministry of Health (MOH, China), Special report 2003. Available at: http://www.tech.net.cn/y-jxgg/zysd/6238.shtml (Accessed 12 July 2020). Sun, S., Xie, Z., Yu, K., Jiang, B., Zheng, S. and Pan, X. (2021) ‘COVID-19 and healthcare system in China: Challenges and progression for a sustainable future’, Globalization and Health, 17 (1), pp. 14–14. doi:10.1186/s12992-12021-00665-00669. Sun, Y.F., Yan, L.H. and Kang, F.X. (2001) ‘The psychological reasons and countermeasures for nurse leaving their posts’, Chinese Journal of Nursing, 36 (2), pp. 92–94 (in Chinese). Wang, H.L. (2016) ‘The BRICS memorandum of understanding on nursing cooperation was signed in Beijing’, Chinese Journal of Nursing, 52 (1), p. 66 (in Chinese). WHO – World Health Organization. (2006) World health report (2006): Working together for health. Geneva: World Health Organization. WHO – World Health Organization. (2018) World health statistics 2018: Monitoring health for the SDGs, sustainable development goals, Geneva: World Health Organization. WHO – World Health Organization (2020) State of the world’s nursing 2020, Geneva: World Health Organization. Williams, G.A., Maier, C.B., Scarpetti, G., de Belvis, A.G., Fattore, G., Morsella, A., Pastorino, G., Poscia, A., Ricciardi, W. and Silenzi, A. (2020) ‘What strategies are

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countries using to expand health workforce surge capacity during the COVID-19 pandemic?’ Eurohealth, 26 (2), pp. 51–57. Wu, X.J. (2019) ‘Boosting nursing cooperation for a Healthy Silk Road’. Belt and Road International Congress, reported by the President of Chinese Nursing Association (CNA), 6 September2019, Beijing. Wu Y. (2019) ‘The role of nursing research in tackling NCDs in China’, reported by the Vice President of CNA,23 May 2019. Xiao, J., Zhu, J.H., Ye, W.X., Zheng, X.P., Wang, L.C., Jin, J.F. and Sun, Y.Y. (2021) ‘Human resource management of senior nurses: A literature review’, Chinese Journal of Nursing Management, 21 (10), pp. 1447–1450 (in Chinese). Xu, L. (1997) ‘Enlightenment of sending nurses working in the United Arab Emirates’, International Economics Cooperation, 8, pp. 18–19 (in Chinese). Xu, Y. (2003) ‘Are Chinese nurses a viable source to relieve the U.S. nurse shortage?’, Nursing Economic, 21 (6), pp. 269–274. Xu, Y. (2004) ‘International nurse migration’, Journal of Nursing Scholarship, 36, (3), p. 189. Xu, Y. (2005) ‘Clinical challenges of Asian nurses in a foreign health care environment’, Home Health Care Management and Practice, 17 (6), pp. 492–494. doi:10.1177/1084822305278127. Xu, Y. (2006). ‘From diplomacy to national development: Evolution of Chinese policy on the international mobility of nurses’. Harvard Health Policy Review, 7 (1), pp. 121–132. Xu, Y. and Zhang, J. (2005). ‘One size doesn’t fit all: Ethics of international nurse recruitment from the conceptual framework of stakeholder interests’, Nursing Ethics, 12 (6), pp. 571–581. doi:10.1191/0969733005ne827oa. Ye, W.Q., Du, P. and Xu, X.P. (2006) ‘Study of the current situation of nursing resource allocation in Shanghai’. Chinese Journal of Nursing, 41 (10), pp. 874–876 (in Chinese). Zhang, J.J, Chen, S.Y, and Liu, Y. (2013) Investigation on the status quo of Chinese nurses’ practice abroad. Chinese Nursing Management, 8, pp. 37–39. Zhou, Y., Windsor, C., Theobald, K. and Coyer, F. (2011) ‘The concept of difference and the experience of China-educated nurses working in Australia: A symbolic interactionist exploration’, International Journal of Nursing Studies, 48 (11), pp. 1420–1428. doi:10.1016/j.ijnurstu.2011.05.003. Zhu, J.H. (2012) Towards an understanding of nurses leaving nursing practice in China. PhD thesis, University of Edinburgh. Zhu, J.H., Rodgers, S. and Melia, K.M. (2014) ‘The impact of safety and quality of health care on Chinese nursing career decision-making’, Journal of Nursing Management, 22 (4), pp. 423–432. doi:10.1111/jonm.12140. Zhu, J.H., Rodgers, S. and Melia, K.M. (2015) ‘A qualitative exploration of nurses leaving nursing practice in China’, Nursing Open, 2 (1), pp. 3–13. doi:10.1002/nop2.11. Zhu, J.H., Rodgers, S. and Melia, K.M. (2018) ‘Understanding human resource wastage in the nursing shortage: Lessons learned from Chinese nurses leaving nursing practice’, Athens Journal of Health, 5 (3), pp. 195–212. doi:195-21110.30958/ajh.5-3-2. Zhu, J.H., Stone, T. and Petrini, M. (2020) ‘The ethics of refusing to care for patients during the coronavirus pandemic: a Chinese perspective’. Nursing Inquiry, 28 (1), p. e12380. https://doi.org/10.1111/nin.12380.

4

Career pathways, long-term settlement policies and stepwise migration aspirations of Philippine-educated nurses in Singapore Lessons for policymakers Maria Reinaruth D. Carlos*

Introduction Along with international recruitment, the retention of skilled and experienced foreign-educated nursing staff is a critical policy instrument in human resources for health workforce planning and management. The demographic, structural, and economic, transformations in both sending and destination countries in recent years have led to the expansion of the international labour market for nurses, offering them more job opportunities. At the same time, it has been observed that many nursing graduates from sending countries embark on a stepwise migration, in which they work in several “transit” destinations before reaching their most preferred destination (Carlos 2013). With this in mind, it is essential to explore and understand the issue of why some foreign-educated nurses, already in one destination, decide to stay, and why others prefer to move on to the next destination. In short, who aspires to move, and who aspires to stay, and what factors are influential in their decision making?1 In this chapter, the “stay” or “leave” aspirations of Philippine-educated nurses (PENs) in Singapore is analysed. This country is an interesting case in point, because of its geographical proximity to the Philippines, and its “active, open and transparent recruitment policy for foreign nurses” (Matsuno 2009: p.11). Moreover, many recruiters from other destinations such as the UK and UAE come regularly to Singapore to interview PENs. This is a more practical way of recruiting, as they already have experience of working overseas. In addition, recruiters do not need to deal with local recruiters, and the Philippine Overseas Employment Agency (POEA). For PENs, Singapore provides them with more opportunities to work in another destination. Given their current greater access to more destinations, this chapter seeks to “unpack” the question of whether these nurses aspire to stay, or whether they opt to leave for the next destination following a stepwise migration pattern. Taking the case of Singapore, this chapter also explores how the occupation and migration policies in their current destination, particularly those related DOI: 10.4324/9781003218449-5

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to long-term settlement, are associated with individual migration decisions. In previous studies, it has been emphasised that naturalisation, or granting of citizenship, and family reintegration are all crucial in the choice of the next or final destination (Carlos 2014). This study contributes to the literature by showing that, in a destination with restrictive long-term settlement policies, or where it is difficult to implement such due to perceived high social and other costs, PENs are still likely to aspire to stay if there is a career pathway system or scheme, through which they can be promoted, based on their professional skills, and educational credentials. The study results were derived from a questionnaire survey, conducted in 2017 with 264 PENs working in Singapore. This chapter is organised as follows. Section 2 examines the existing literature on stepwise migration and destination choice behaviour of migrant nurses. It is followed by the details of the methodology. After describing the migration routes of PENs to Singapore, the results and analysis of the empirical data are discussed in subsequent sections. The final section summarises and draws policy implications for countries that are reluctant to implement long-term settlement policies, such as Japan.

Stepwise migration and the choice of destination The fact that migrant nurses use some destinations as a “stepping-stone” is well documented in the literature (Carlos and Sato 2011, 2010; Matsuno 2009; Kingma 2008; Buchan et al. 2005). This phenomenon is also referred to as the stepwise (or multistep) migration pattern (Paul 2011), or onward migration (Humphries et al. 2009). The process of choosing and sequencing the transit and final destinations is dynamic and complicated, and the worker might, or might not, have planned the hierarchy and sequence of destinations, and the timing of any migration, prior to departure from his or her home country. In this study, attention focuses on the personal attributes of the worker, working conditions and satisfaction at work, and the worker’s perceptions of the long-term settlement policies of the host country (Singapore); as they are key factors affecting the stay-or-leave decision of PENs, in the context of their stepwise migration behaviour. In the case of Singapore, a study by Goh and Lopez (2016) found that work satisfaction was based on two criteria. The ability of nurse managers to lead a ward and their practice environment (the general or specialty area to which they were assigned) were statistically significant determinants of the leave–stay decisions of foreign nurses. The survey explored the aspirations of registered nurses from several source countries to leave their job in Singapore, but it did not interrogate the issue of which would be the next destination for these nurses, which could be another workplace in Singapore, or another (a more preferred) destination, or their home country. The findings in this chapter add to this growing literature by looking at the behaviour of nursing

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graduates from the Philippines, the largest group of foreign-educated nurses in Singapore, with regards to their preferences for subsequent destinations, and their motivations for moving. At the macro-level, long-term settlement policies have been cited as influencing the decision to remain in one destination or move to another place. Despite a lower income or fewer career opportunities, a worker may still choose not to leave a destination, provided it allows for family integration, or better cultural adaptation (Carlos 2014; Humphries et al. 2009). As a concrete example of how such migration policies affect the selection of destination, Humphries et al. (2009: p. 50) concluded that, for foreign nurses in Ireland, “the acquisition of a permanent nursing post means little if not accompanied by long-term residency and citizenship rights for migrant nurses and their families.” These are perceived by migrants as two main factors affecting their chances for long-term settlement in a destination. There are cases, however, where the relationship between these policies and destination preferences may not be as “straightforward”, and relaxing or restricting migration policies may not be enough to ensure that migrants will choose a certain destination or not (Crawley and Hagen-Zanker 2018: p. 21). For instance, with reference to the refugees, Christensen et al. (2017: p. 220) argued that while immigration policies acted as a context for individual aspirations, it was their subjective consideration of these policies and social networks in the destination that facilitated their migration to one destination. This study has attempted to explore how PENs’ perceptions of the long-term settlement policies, as a subset of immigration policies,2 can affect their migration patterns and choices of destination. Finally, the chapter also explores the effect of other potential factors affecting the stay-or-leave decision of PENs, such as their socio-demographic profile, namely age, gender, marital status, and their education level.

Methodology The data for this chapter were derived from qualitative and quantitative fieldwork research conducted in August to December 2017. Quantitative data were collected through the implementation of a three-page survey questionnaire, written in English, to Philippine-born nurses, who graduated from the four-year nursing degree (Bachelor of Science in Nursing) in the Philippines. The pretested questionnaire included questions about their motivations for taking up nursing, the factors considered in choosing their destinations, and their plans for staying or leaving Singapore to work in another destination. Demographic data were also collected from the respondents.3 Using a snowball sampling method, the survey was implemented with the help of two Filipino research assistants, one Enrolled Nurse (EN) and one Registered Nurse (RN). The respondents were identified sometimes through being introduced, and also during visits in hospitals and other facilities, and also in nurse dormitories and places within and around local areas where

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Filipinos usually congregate. When face-to-face surveys were not possible, due to lack of time and space, the forms were left with the respondents and, when completed, were collected later. The feedback from the 264 respondents comprising 114 RNs, 62 ENs and 88 Nursing Aides (NAs) and Health Care Assistants (HCAs), was gathered. All except three of them were first-time migrants. The descriptive statistics of the respondents are shown in the Appendix 4.1. Given that it was administered to a limited-size sample, through a snowball sampling method, the estimates may be subject to bias. As such, the results can be considered as trends, rather than a generalised representation of the entire population of PENs in Singapore. During the fieldwork, focus group discussions (FGDs) and interviews with 20 PENs (ten NAs, seven RNs and three ENs) and four university researchers were also conducted. During these FGDs, personal narratives of PENs’ experiences were sought and explored to gain a deeper understanding of individual attitudes and views about the nursing profession in general and foreign nurse experiences in particular. The conversations were recorded and analysed. In addition, their opinions expressed in the descriptive questions in the questionnaire were also collected. Before conducting the interviews and survey, all participants were briefed about the topic and purpose of the survey, their rights, and provisions for privacy protection. They were then requested to answer the questionnaire if they understood the details explained to them as an indication of their informed consent. Ethical permission to conduct the study was obtained from the Institutional Review Board of Ryukoku University in Japan prior to the implementation of this study.

Foreign-educated nurses in Singapore Currently, there are four major types of occupations in which foreign-educated nurses are employed in Singapore’s medical and long-term care sectors: staff or registered nurses (RN), enrolled nurses (EN), nursing aides (NA), and health care assistants (HCA), with only the first two considered as professional nurses requiring registration from the Singapore Nursing Board (SNB). These occupations differ in job contents, salary and benefits and type of working visa, with the RNs getting the most favorable treatment, followed by the ENs and then the NAs and HCAs who are placed at the bottom of the nursing hierarchy. Most of the RNs and ENs are employed in hospitals, while many of the NA/HCAs work as support care staff in nursing homes, welfare homes for the destitutes, psychiatric facilities as well as step down care facilities such as community hospitals (Lien Foundation 2018). To be able to work as an NA, a foreign-educated nurse must have taken the training programme certified by SNB. For HCAs, it is preferred but not required to have a relevant certificate from the Institute of Technical Education (ITE) in Singapore. In the case of PENs, currently, there are two pathways that can be taken to work as an RN in Singapore. The first pathway is by passing the licensure examination prior to arrival and get hired as an RN (or in some cases, EN)

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immediately. Under this scheme, Singapore placement agencies and employers conduct a recruitment trip to the Philippines to interview applicants and administer the SNB licensure examination there (Boss Job 2021). To qualify for the examination, the PEN should have a nursing degree, a Philippine nursing license and relevant experience in nursing. Once they pass the examination, they are issued a conditional license that permits them to work in a hospital or nursing home in Singapore. However, given these stringent requirements and the limited positions for RNs and ENs, the majority take the second pathway, which entails working initially as an NA or HCA in Singapore for at least two years. They can either apply with a recruiter based in the Philippines, online, or with an agency in Singapore (initially arriving as a tourist). Under this more common pathway, a nursing graduate in the Philippines is accepted as an NA (Chua 2020). Since around 2010, Singapore has seen an increase especially in the number of RNs as well as growing dependence on foreign nurses, particularly PENs, as shown in Figures 4.1–4.2 in which RNs and ENs from the Philippines increased by 123% and 62% respectively. By 2020, there were 5,409 RNs and 2,090 ENs from the Philippines, comprising 15.61% and 28.08% of the total respectively (SNB 2021). The other sources of foreign nurses are Malaysia, China, Myanmar, and India. On the other hand, there are no available

Figure 4.1 Number of RNs in Singapore (Singapore citizens and permanent residents – PR); Filipinos and other foreigners (2011–2020) Source: SNB – Singapore Nursing Board (2021).

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Figure 4.2 Number of ENs in Singapore (Singapore citizens and permanent residents – PR); Filipinos and other foreigners (2011–2020) Source: SNB – Singapore Nursing Board (2021).

statistics on the actual number of foreigners working as NA/HCAs in Singapore. However, the Lien Foundation (2018) estimated that Singapore’s longterm care sector heavily relies on foreign workers, with as high as 85% of all NA/HCAs born in other countries. Khalik (2016) estimated that by 2020, 30,000 more nurses would be needed in Singapore. Aside from the ageing of the population, the new demand also comes from the workforce requirements of new hospitals that are built to cater to the medical needs of the public and in medical tourism. As such, the positions of registered nurse, enrolled nurse and healthcare assistant topped the list of professionals, managers, executives, and technicians (PMET) occupations with vacancies that were hardest to fill (Awang 2021). The government is also building longterm care institutions and acute and community hospitals to cater to the healthcare needs of the elderly, requiring more HCAs and NAs (Chua 2020). Moreover, the demand for foreign nursing graduates to work as private nurses in the homes of the elderly has been on the rise in line with the government’s policy to shift the “centre of gravity” from the hospitals to homes and communities. As a result, there is an emerging market for home care or private nurses, many of them nurses or nursing aides educated in Myanmar, the Philippines and Indonesia (Abu Baker 2021; Wong 2016).

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While more and more foreign-educated nurses get access to the country’s labour market, it also appears that they have higher propensity to leave the country compared to local nurses (Lien Foundation 2018: p. 28; Matsuno 2009). Singapore is considered as a stepping-stone by foreign nurses and nursing aides who were eyeing for better compensation packages in other destinations, in the process of their stepwise migration. In this regard, retention of foreign health workers alongside their recruitment becomes an issue to be considered by the government in destination countries. In the light of the increasing demand for nurses amidst its global shortage (WHO 2020), the question about what the host country can do to entice the skilled and talented foreign-educated nurses to stay emerges as a leading policy concern.

Who aspire to leave and to where? To capture the PENs’ aspiration to leave or stay in Singapore, the question “Do you have plans to leave Singapore to work in another destination?” was asked. Of the 264 PENs, 164 or 62.1% would like to leave the country, while the rest wanted to stay (see Table 4.1). When they were further grouped based on current occupation, the percentage of those who aspire to leave was highest among the NA/NCA group, (80.46%). Meanwhile, the highest percentage of those who aspire to stay (answer: “no”) was among the ENs. To further investigate whether there are differences among the three groups in terms of their aspirations to stay or leave, the chi-squared test of association was performed. It was found that there was a statistically significant difference in the proportions (of “stayers” and “leavers”) between RNs and NAs/HCAs and ENs and NAs/HCAs, but not between RNs and ENs, at p>0.05. These findings imply that the current occupation is one factor that determines the aspirational choice of nurses to stay in Singapore or continue with their stepwise migration project. Moreover, these Table 4.1 Aspirations of PENs regarding work migration to another country (n=264) Question: Do you have plans to leave Singapore to work in another country?

No

Yes

Total

Current occupation in Singapore

50 43.86% 33 52.38% 17 19.54%

64 56.14% 30 47.62% 70 80.46%

114 100.00% 63 100.00% 87 100.00%

100 37.88%

164 62.12%

264 100.00%

Staff (Registered) Nurses (RN) Enrolled Nurses (EN) Nursing Aide/Health Care Attendants (NA/HCA)

Total

Source: Author’s computation from survey data

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ratios are generally higher than those that registered in a previous study by Carlos (2013) in 2010–2011 (n=53) (from 54.7% to 62.1). This change can be attributed not only to the changing employment and migration conditions in Singapore, but also to developments in the global demand for nurses as mentioned above.4 The 164 respondents who had aspirations to leave Singapore were further asked to list the top three destinations where they prefer to work after Singapore, and the results are to be found in Figure 4.3. Canada topped the list, with all categories of PENs identifying it as one of their three top destinations. It was followed by USA, UK, Australia and New Zealand. On the other hand, the second and third preferences seemed to vary depending on the categories. For instance, for RNs, the second and third choices were UK (45.33%), and Australia (40.63%) respectively. On the other hand, next to Canada (68.97%), ENs’ choices were the USA (55.17%) and New Zealand (51.72%). These values are higher than those of the other categories in the same destination. Moreover, RNs and NA/HCAs seem to be more inclined to go to Australia compared to ENs. Why has Canada led the USA and UK as the most preferred destination for PENs in this study? In terms of salary compensation, the Organization for Economic Cooperation and Development (OECD 2019) reported that in 2017 (or nearest year), the average annual salary (based on US$ PPP) of hospital nurses in Canada (US$57,000) was lower compared to the United States’ US$75,800 and Australia’s US$67,700. The annual salary in New

Figure 4.3 Top three destinations of PENs aspiring to migrate and work in another destination (M.A.) Source: Own survey data.

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Figure 4.4 Top (first) choice of destinations of PENs aspiring to leave Singapore (choose only one) (% of total per category) Source: Own survey data.

Zealand, the UK and Japan around the same year were US$53,900, US $50,800 and US$45,200 respectively.5 That Canada was the top choice suggests that in the PENs’ stepwise migration project, there are factors other than salary (economic remunerations) that they consider in the choice of the next transit, or even the final destination. The respondents were further asked to identify the destination where they have the strongest aspiration to go; and the results are shown in Figure 4.4. The country considered as the most preferred or top choice was again Canada, followed by the USA and UK. The percentage of those whose top choice was Canada was highest for ENs, followed by RNs and lastly by NA/ HCNs, who are also most inclined to go to the USA. It is also interesting to note that those who are already working as RNs in Singapore are not strongly inclined to work in Japan. One of the reasons was the higher annual salary for RNs in Singapore (Lien Foundation 2018). On the other hand, compared to other categories, a higher proportion of NA/HCAs have European countries (UK at 18.31% and EU at 9.86%) as their top choice and further investigation is necessary to understand this trend.

Factors affecting the aspiration of PENs to leave Singapore What factors then contribute to the PENs’ aspiration to stay in the current destination or leave for the next one? To answer this, a binomial logistic regression in which the dependent dummy variable is “1” if the respondent has plans or aspiration to leave Singapore, and “0” if otherwise, was performed. Following previous research discussions, three sets of predictors were

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included: (1) the work-environment related factors, such as type of facility (=1 if publicly funded, 0 if otherwise), the general work satisfaction index6 and current occupation (RN, EN or NA/HCA); (2) the demographic factors such as gender (=1 if male, 0=female), marital status (=1 if single, 0 if otherwise), years since graduation from nursing course as a proxy for age and number of years working in Singapore, and (3) variables that reflect the subjective consideration of PENs regarding migration factors such as geographical proximity and long-term settlement policies on the acquisition of citizenship and family reunification. The results are presented in Table 4.2. Here, a positive coefficient for an independent variable means that compared to the base (for categorical variables) or, as the value increases (for nominal variables), there is a higher Table 4.2 Result of the logistic regression predicting the likelihood of Philippine-educated nurses (PENs) to aspire to leave Singapore Dependent variable 0=stay; 1=leave Variables in the equation

B

Exp(B) (oddsratio)

Type of setting (base: non-hospital)

-0.365

0.694

0.301

Type of facility (base: private) Gender (base: female)

-0.740 0.547

0.477 1.729

0.028 0.087

Marital status (base: married)

-0.657

0.518

Current occupation (base: RN) (EN) (NA and HCA) Years since graduation (in years) Years working in Singapore (in years) How important is “can obtain citizenship”in your choice of destination (1: not important to 4: very important) How important is “family reunification” in your choice of destination (1: not important to 4: very important) How important is “near Philippines” in your choice of destination (1: not important to 4: very important) Work satisfaction index (1: very unsatisfied to 4: very satisfied) Constant Cox & Snell R Square: 0.241

Sig.

0.108 0.000

** **

-1.617 -1.899 0.158 -0.231 0.172

0.199 0.150 1.171 0.794 1.188

0.000 0.000 0.032 0.010 0.442

0.146

1.157

0.614

-0.065

0.937

0.811

-1.045

0.352

0.005

4.562

95.767

0.001

Nagelkerke R Square: 0.330

Source: Author’s calculations Note: ** statistically significant at 1%; * statistically significant at 5%

*

** * **

**

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likelihood of aspiring to leave Singapore for the next destination. A negative coefficient on the other hand means lower likelihood. The model correctly classified 73.5% of the 264 cases, with a Nagelkerke R2 value of 0.330. The estimated coefficients for type of facility, current occupation, years since graduation, years working in Singapore and work satisfaction index were found to be statistically significant; while those of the migration-related factors and personal attributes such as marital status and gender were not.7 The odds-ratio for the type of facility was 0.477 (negative coefficient), which suggests that those who were working in publicly funded facilities were less likely to plan to leave Singapore, or conversely, those who work in privately owned hospitals and elderly care facilities were 2.09 times (=1/0.477) more likely to leave than those who work in public hospitals and long-term care facilities. The participants mentioned that although the salaries between publicly funded and privately owned facilities were comparable, those who worked in the former received more benefits such as annual bonus and incentive pay. This could be a result of the Singaporean government’s efforts to keep nurses in public institutions through raising the salary of its RNs by 20% (Lai 2014a) in 2015. However, while salary is effective as a retention measure, nurses point out that improved economic rewards are not enough. Granting more autonomy in the wards, lighter workload and opportunities for career progression were suggested to entice nurses to stay in these government hospitals (Lai 2014b). Meanwhile, the odds-ratio of the variable “years since graduation” is greater than one, implying that PENs who are older in the profession are more likely to leave the country, but only slightly by 1.171 times. This result is compatible with the human capital theory of migration set forth by Schwartz (1976). Also, it was found that the perception of the respondents in terms of their general satisfaction in the current work also plays a role in (slightly) weakening the aspiration of a PEN to leave Singapore, as shown by the negative and statistically significant coefficient (-1.045) of the variable “work satisfaction index”. Those who are less satisfied are 1.284 times more likely to aspire to leave Singapore. Those who had been working in Singapore for a longer time had less likelihood to aspire to leave Singapore (odds-ratio of 0.794). For each year longer that the nurse works in Singapore, the odds of aspiring to leave this country decreases by a small factor of 1.26. This finding can also be an indicator of their social integration in the country. Having a big Filipino community even in the workplace, easy access to Filipino food, convenient mass transport system, having English as one of the official languages and similar weather with that in the Philippines contributed to the ease in their adjustment and settlement (FGD November 2017). Some PENs, in their comments in the survey, described Singapore as my second home indicating that they have adapted well at work and life in this country. However, the relationship between geographical proximity and the likelihood to aspire to leave Singapore was not confirmed in this study.

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Intuitively, those who have a strong preference to migrate to a destination near the home country are more likely to aspire to stay in Singapore because among the countries that employ Filipino nurses, it is the nearest to the Philippines. Conversely, ceteris paribus, those who do put less importance on geographical proximity may be more inclined to aspire to leave Singapore for another destination, farther than Singapore from the Philippines. One plausible explanation why distance could have ceased to be statistically significant in choosing a destination was that physical distance could be substantially substituted or complemented by advances in information and communication technologies such as the internet and mobile phone and social media such as Facebook or Skype and cheaper travel cost.

Long-term settlement policies and the aspiration to stay or leave Meanwhile, the odds-ratios for the variables representing the importance that PENs placed on long-term settlement policies in the choice of destination were greater than one (see Table 4.2), suggesting that those who put more importance on these policies are more likely to leave Singapore. However, the results were not statistically significant.8 In the sample used in this study, these odds-ratios are not different from zero, implying that the subjective importance put by the respondents on these policies, or whether these policies are important for them or not, may not affect their decision to stay or leave Singapore. PENs prefer to stay in Singapore even in the case when long-term resident policies are lacking or restrictive. For them, these policies may not have mattered even at the time they left the Philippines to work overseas, and other factors, such as career progression and work satisfaction emerge as more important determinants (further discussed below). Indeed, Singapore’s long-term policies towards foreign workers are stricter compared to other destination countries for nurses, such as the UK, Australia and the US. According to the ICA (2021), to apply for a permanent resident (PR) visa, the worker must possess either an S-pass or employment pass that requires a monthly fixed salary of at least S$2,500. This set minimum is below the median basic salaries of $2,444 and S$1,824 respectively for Singapore nationals and permanent residents as reported by the Ministry of Manpower Singapore (MOM 2021c). Foreign workers earn less (Lien Foundation 2018). Moreover, the PR is valid for five years, and is not automatically renewed. It can also be lost if the residency requirement is not met, or a valid re-entry permit is not secured prior to departure from the country. That the PR status is difficult to achieve is also shown by the limited number of slots available. In 2015–2019, the number of foreigners granted PR was stable at about 31,700 annually (Sin 2020) while the total number of PRs remained constant in the same period, at about 520,000 (Department of Statistics Singapore 2021). Family integration is also based on migrant workers’ salary and visa status. Those who possess either an S-pass or an employment pass earning a minimum fixed monthly salary of S$6,000 can apply for a dependant’s pass or a

Philippine-educated nurses in Singapore

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long-term visit pass for their family members (MOM 2021b). Obtaining Singaporean citizenship by registration is also competitive with a limited number of available slots, stiff requirements, and rigid screening. The number of permanent residents who were granted citizenship was steady at around 18–19,000 annually in 2017–2019 (Choo 2020). Singapore also does not allow dual citizenship, which is in contrast with the more preferred destinations like Australia, New Zealand, and the UK. The stringent rules regarding family reunification for migrant workers results in many PENs in Singapore leaving their families in the Philippines. What could have compensated for such lack of long-term policies in the case of the respondents in this study? The next section looks more closely at their work satisfaction and current occupations as potential strong factors in the retention and choice of destination.

Current occupation, work satisfaction and the aspiration to leave Singapore The results of the binomial regression show that the current occupation in Singapore stands as a factor in the aspiration of PENs to leave Singapore. The coefficients for ENs and NA/HCAs were negative and highly statistically significant, indicating that compared to RNs, ENs are 5.025 (1/0.199) times; and NA/HCAs 6.66 (1/0.150) times more likely to aspire to leave Singapore. This suggests that setting up a career progression system that is more accessible to foreign educated nurses9 is effective in enticing them to aspire to stay, and thus can be used as a retention tool when long-term settlement policies are selective, lacking or difficult and costly to implement. While there is a career progression system, from NA/HCA to EN, then to RN and APN in Singapore, this is not easy. Only NAs/HCAs who have passed the licensure examination in the Philippines can qualify to take the Technical Education (ITE) course in Health Care, the first step to become an EN in Singapore. However, this course and the ensuing examination can only be taken under the sponsorship and endorsement of the employer and depends on the availability of positions for ENs or RNs in nursing homes and hospitals. In reality, many NAs and HCAs end up in support care roles – where most of the vacancies are (Lien Foundation 2018). One informant mentioned about the “glass ceiling” and that “it is not easy for NAs to get promoted to EN or RN because even taking the licensure examination requires endorsement or recommendation from the Singaporean superior, ” and they cannot directly apply for it.10 Some of the NA/HCAs interviewed also felt frustrated with the long waiting time and difficulty, as well as the “politics” entailed in order to get promoted. There are several mechanisms in which the type of occupation impacts on the aspiration to leave or stay. The most obvious is the difference in remunerations. In terms of salary, for example, during the time of the survey (2017), the PENs working as NAs in the sample earned around S$800–950

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(US$600–710)11 per month plus allowance for lodging. They did not get an annual bonus but received a gratuity of two-months’ worth of salary after completion of a two-year contract.12 On the other hand, in the same period, a foreign EN’s monthly take-home salary ranged from S$1,200 to S$1,600 (US $883–1,178), and for RNs, from S$1,800 to S$2,500 (US$1,325–1,840) and could go up as much as S$3,000 (US$2,208) with longer experience.13 The inability to fully practice the profession for NA/HCAs is also another important reason that positively impacts on their aspiration to leave. Foreign HCAs and NAs work as “rank and file care staff” mainly in nursing homes and community or rehabilitation hospitals being involved in basic but important tasks, i.e. feeding, helping with medication and showering residents (Basu 2016). They are not allowed to perform clinical nursing procedures such as preparation of medicines and intravenous injection and dressing of complex wounds. On the other hand, RNs are allowed to fully practice (and ENs to some extent) their nursing skills both in the hospitals and in nursing homes (Singhealth 2019). The work permit (visa) issued to NA/HCAs is also more restrictive than that issued to RNs in terms of rules and privileges as foreign workers. The work permit needs to be renewed every two years, again upon recommendation of the employer. Change of employer is also not allowed unless the NA/HCAs returns first to the home country. Holders of work permit need to get the approval of the MOM if they want to marry a Singapore national or a permanent resident. Unless married to a Singapore citizen or permanent resident, a work permit holder can neither get pregnant nor deliver a child in Singapore during the validity of the work permit. These rules are not enforced in the cases of ENs and RNs who acquire an S-pass visa14 for semi-skilled workers. However, regardless of the type of occupation, the employer is required to “supervise and control” the foreign-educated nurses and pay the foreign worker levy (MOM 2021a). The RN group had the highest proportion of members who aspire to stay in this country because they enjoy the privileges of being at the top of the foreign nurses’ hierarchy. The RNs interviewed pointed out that they were already “happy” and “content” with their salary, working conditions, relationship with co-workers and career growth in Singapore, especially when they compared these with their previous situation in the Philippines. They also felt professional growth in their work, which included being able to use advanced medical technology. When one RN participant was asked why she did not want to go to the UK or Australia even if, with her qualifications and experience as a Singapore-trained foreign nurse she could easily do so, she replied that “doing all the process (of applying for a job and settling down) is not worth my (her) efforts” and one claimed that she “had already established (her) self in Singapore”. The salary increases from 2015 were also one of the main reasons given by respondents. One RN commented in the survey questionnaire that working in Singapore was a “match made in heaven”. Indeed, the RNs who are on top of the nursing occupational hierarchy aspire to stay

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in this country because of their positive experiences of living and working in Singapore. That the general work satisfaction contributes to the aspiration of respondents to stay in Singapore is manifested in the odds-ratio of “work satisfaction index” of 0.352 in Table 4.2. This means that those who are more satisfied with work in general are less likely to aspire to leave Singapore. As the general level of satisfaction of the respondents increases by one unit, the odds of aspiring to leave this country decreases by 2.84 (1/0.352). This finding is comparable with the study made by Goh and Lopez (2016: 897) where they argued that higher work satisfaction, as reflected in their perceptions of nursing practice environment and relationship with supervisors, indeed reduces the intention to leave of nurses. This study also confirms, through an empirical exercise, the positive role of job satisfaction in keeping nurse professionals as discussed by Buchan et al. (2018), Buchan et. al (2015), and Coomber and Barriball (2007).

Policy implications and final comments This empirical exercise has found that the PENs’ current occupation, years since graduation and years of stay in Singapore have statistically significant impacts on the aspiration to stay, while long-term settlement policies did not appear to have any influence on their aspiration. This suggests that providing career opportunities and creating a career pathway accessible to foreign nurses are effective as a retention policy. Moreover, it implies that even when long-term settlement policies are restrictive, lacking or absent, RNs may choose to stay – and one of the reasons as shown here is because they are on top of the occupation hierarchy, which offers them higher wages, better use of nursing skills learned in the home country, acquiring more and better nursing skills, professional recognition and less restrictive foreign worker rules and regulations. While currently it is very difficult for them to stay for as long as they want to, they are happy to stay just yet because of the privileges and satisfaction working as RNs. On the other hand, the NA/HCNs who are at the bottom of the professional hierarchy are more likely to aspire to leave. However, ironically, they are also the ones who are less likely to successfully carry out their plan to reach the next destination in their stepwise migration project. As NAs or HCAs, they earn much less than RNs and thus have limited capacity to pay for the expensive recruitment fees in more preferred destinations. They learn fewer, or even lose professional nursing skills that are required and/or highly appreciated by employers in other destinations.15 For the NAs and HCAs, therefore, Singapore becomes a “destination trap” that prevents them from continuing their migration journey. Another important implication of the study findings is the role of a career pathway in screening the foreign-educated nurses and attracting those who are more capable, well-trained, and most suitable ones (in this case the RNs)

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to stay longer. This is important especially when the global demand for nurses is expanding and competition among the destinations for the most talented is stiff. Singapore can attract especially first-time migrant nurses from Asian countries because compared to other popular destination countries (such as the US, the UK and Canada), recruitment is relatively easy, fast, and cheap. Also, unlike in other destinations where adaptation programmes or additional education is required to be able to work, foreign nurses in Singapore are allowed to train and work immediately as NA/HCAs after completing a brief orientation upon arrival. In this way, foreign-educated nurses can promptly fill the shortages. At the same time, it is also advantageous for the foreign nurses because they can earn money soon after arrival. However, if they aspire to become an EN or RN, they must compete for the limited number of available positions in the workplace, and only those who are successful in passing the licensure examination, perform well, and are recommended by their supervisors are promoted. Meanwhile, those who do not meet these standards remain at the bottom of the nursing hierarchy and have a stronger aspiration to leave. To further provide incentive to foreigneducated RNs in Singapore, the government hospitals around 2015 initiated a salary increase from S$1,300 to S$2,000 starting salary and opened the postgraduate programs (ex: Advance Practice Nursing) to foreign nurses for their career advancement. As a result, “For RNs, Singapore has become less of a stepping-stone”.16 Finally, the findings provide hints for other destinations experiencing labour shortages but are hesitant to provide long-term settlement schemes for a foreign workforce. For instance, Japan has a long history of adopting its own “guest worker policy” in which only the skilled workers are issued working visas and long-term settlement policies are lacking or restrictive, such as the required ten years of residence before qualifying to apply for permanent residency, allowing the petition only of spouse and children, and prohibition of dual citizenship. It was only from 2019 that the Abe administration began to issue the specified skilled worker (SSW) visa to foreign workers in 12 specified industry fields, such as nursing care, hospitality, agriculture and food service, after passing a Japanese language test and a skills proficiency examination (Immigration Services Agency of Japan 2022). In the cases of countries that are hesitant to implement radical long-term settlement policies, an alternative policy could be to introduce a transparent and feasible career pathway that recognises them as professional nurses and allows them to enjoy professional autonomy, economic rewards and work satisfaction.

Notes * The author would like to acknowledge the support of the Institute of Developing Economies -JETRO (IDE-JETRO) and Research Institute for International Society and Culture of Ryukoku University in the gathering of data and writing of this chapter. Some sections of this chapter drew from a report submitted to IDE-JETRO

Philippine-educated nurses in Singapore

1 2 3 4 5

6

7

8 9 10 11 12 13

14

89

entitled “Will they leave or will they stay? Occupation, migration policies and stepwise migration of Philippine-educated nurses (PENs) in Singapore” in March 2019. The views expressed as well as errors are those of the author and do not reflect the position of her affiliations. This study is limited to the “aspirations” and “preferences” of migrants. It is subjective, and whether and when these aspirations are or can be realised is not discussed in this chapter. Another important subset of migration policies includes those that are related to access to the destination’s labour market, specifically policies on what kinds of foreign workers and under what conditions they will be hired. The questionnaires are available upon request from the author. In the 2017 questionnaire, “not sure” was not included in the choices. Interestingly, in the 2010 survey, no one indicated that they wanted to stay in Singapore, but rather, they were “not sure” of whether they wanted to leave or stay in Singapore at that time. Amounts are in purchasing power parity (PPP) values. Data for the US refer to registered (“professional”) nurses (which may result in an over-estimation); while the data for Canada refer to registered (“professional”) nurses and unregistered nursing graduates (OECD 2019). The index for general satisfaction in current work is computed by taking the average of the levels of satisfaction in terms of working conditions, relationship with supervisor, co-workers, patients and respondents, career development, and salary and remunerations – all of which are evaluated with 1: very dissatisfied to 4: very satisfied. There is weak correlation between this index and other variables used in this study. Here, it is used as a rough proximate of the impacts of other factors for satisfaction that are not explicitly used in the estimation. That the coefficient for gender is positive implies that men are more inclined to leave the current destination for the next in the process of stepwise migration. While feminisation has been widely recognised in the literature on health care workforce migration (see for example, Brush & Sochalski 2007), quantitative studies such as Goh & Lopez (2016) and Oda (2018) are not able to provide evidence on the effect of gender on the migration decision. One justification for this is that cited by Bourgeault et al. (2021) that gender is “intricately implicated” through gender-based attitudes and practices in both the source and host countries and may be thus highly correlated with other factors such as preference to take up nursing profession, role in the family and social networks. It is possible that there is statistical bias arising from the sampling methodology and sample size (Nemes et al. 2009) and increasing the sample size may improve the estimation. This is an important topic for future studies. Singapore established the Advanced Practice Nurse (APN) position as a way to entice nurses to stay in the profession (Schober, 2013). Interview on 10 December 2018 with PEN working as an NA for six years. Based on interviews. All exchange rate conversions in this study use the US$ equivalent of Singapore dollar on 9 March 2019, at US$0.736 per one Singapore dollar. Interviewed with an NA newly-promoted to EN, August 2017. Interviews with an RN and an EN, November 2017. These current rates as of 2017 are higher than those quoted by Toyota (2012), thus suggesting that in terms of salary, the conditions for foreign-educated nurses had improved. However, they are lower than that announced by the Ministry of Health in May 2014, to quote: “The average gross monthly salary, after adding in allowances and bonuses, for entry-level registered nurses ranges from S$3,300 to S$5,200 depending on their qualifications.” (Channel News Asia Online News, 2020). An S-pass visa is issued to mid-level skilled staff earning at least S$2,500 per month with relevant qualifications and experience. As of October 2021, the number of workers that an employer can hire is capped at 10% of the total

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workforce in the services sector, 20% in the manufacturing sector and 18% in all other sectors. Moreover, an employer has to pay a monthly levy rate ranging from S$330 to S$650 (MOM 2021a). 15 Tsujita and Oda (2018) observed that nursing graduates from India who work as NA/HCAs in Singapore experience “deskilling”. 16 Interview with a nursing school professor in Singapore, August 2017.

References Abu Baker, J. (2021) ‘Demand for professional caregiving help for the elderly on the rise’, Channel News Asia Online News, 25 April. Available at: https://www.channelnewsasia. com/singapore/singapore-elderly-professional-caregiving-live-in-maids-230901 (Accessed: 14 September 2021). Awang, N. (2021) ‘Nursing jobs among top positions unfilled for at least 6 months in 2020: MOM report’, Today Mobile News. 9 April. Available at: https://www.todayonline.com/ singapore/nursing-jobs-among-top-positions-unfilled-6-months-2020 (Accessed: 10 September 2021). Basu, R. (2016) ‘Safe but soulless: nursing homes need a new narrative’. Lien Foundation. Available at: http://www.lienfoundation.org/sites/default/files/SafebutSoulless_0.pdf (Accessed: 14 September 2021). Boss Job (2021) ‘Staff nurse vacancy (Singapore Nursing Board Exam)’. Available at: https://bossjob.ph/job/staff-nurse-vacancy-(-singapore-nursing-board-exam-)-35272 (Accessed: 10 September 2021). Bourgeault, I.L., Runnels, V., Atanackovic, J., Spitzer, D. and Walton-Roberts, M. (2021) ‘Hiding in plain sight: The absence of consideration of the gendered dimensions in “source” country perspectives on health worker migration’, Human Resources for Health 19 (40). doi: https://doi.org/10.1186/s12960-021-00571-6. Brush, B. and Sochalski, J. (2007) ‘International nurse migration: Lessons from the Philippines’, Policy, Politics and Nursing Practice, 8 (37), pp. 37–46. doi:10.1177/ 1527154407301393. Buchan, J., Jobanputra R., Gaugh, P. and Hutt, R. (2005) ‘Internationally recruited nurses in London: Profile and implications for policy’, King’s Fund Working Paper. London:Kings Fund. Buchan, J., Twigg, D., Dussault, G., Duffield, C. and Stone, P.W. (2015) ‘Policies to sustain the nursing workforce: an international perspective’, International Nursing Review, 62 (2), pp. 162–170. Buchan, J., Shaffer, F. and Catton, H. (2018) ‘Policy Brief: Nurse Retention’. ICNM, Philadelphia, USA. Available at: https://www.icn.ch/sites/default/files/inline-files/2018_ ICNM%20Nurse%20retention.pdf (Accessed: 10 September 2020). Carlos, M.R.D. (2013) ‘The stepwise international migration of Filipino nurses and its policy implications for their retention in Japan’, Afrasia Working Paper Series 23, p. 24. Carlos, M.R.D. and Sato, C. (2011) ‘The multistep international migration of Filipino nurses: The propensity to migrate among Filipino nurses in Dubai’, Journal of the Socio-cultural Research Institute of Ryukoku University, 13, pp. 37–64. Carlos, M.R.D. and Sato, C. (2010) ‘The multistep migration of nurses: The case of Filipinos in the United Kingdom’. Journal of the Socio-cultural Research Institute of Ryukoku University, 12, pp. 5–34. Carlos, M.R.D. (2014) ‘Multiculturalism policies and the stepwise international migration of Filipino nurses: Implications for Japan’, in K. Shimizu and W.S.

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Bradley (eds) Multiculturalism and Conflict Reconciliation in the Asia-Pacific: Migration, Language and Politics, pp. 162–190. London: Routledge. Carlos, M.R.D. (2018) ‘Philippine-educated nurses in Southeast Asian destinations: The cases of Singapore and Thailand’, in Y. Tsujita (ed.) Human resource development, employment and mobility of healthcare professionals in Southeast Asia: The case of nurses. IDE-JETRO Bangkok Research Center (BRC) Research Report No. 22, Tokyo: IDE-JETRO, pp. 40–63. Available at: http://www.ide.go.jp/English/Pub lish/Download/Brc/22.html (Accessed: 10 September 2020). Channel News Asia Online News (2020) ‘COVID-19 swabbers employed on short-term contracts with no additional bonuses, career pathways: MOH’. 15 May. Available at: https://www.channelnewsasia.com/news/singapore/covid19-swabbers-salary-short-termcontract-no-bonus-career-path-12735702 (Accessed: 15 July 2020). Choo, D. (2020) ‘Parliament briefs: More PRs get citizenship but proportion of total new citizens is steady’. Today, 15 October. Available at: https://www.todayonline.com/ singapore/parliament-briefs-more-prs-get-citizenship-proportion-total-new-citizenssteady-spike (Accessed: 10 October 2020). Christensen, K., Hussein, S. and Ismael, M. (2017) ‘Migrants’ decision process shaping work destination choice: the case of long-term care workers in the United Kingdom and Norway’, European Journal of Ageing 14, pp. 219–232. doi:10-1007/s1043310016-0405-0. Chua, G.P. (2020) ‘Challenges confronting the practice of nursing in Singapore’, Asia-Pacific Journal of Oncology Nursing, 7 (3), pp. 259–265. doi:10.4103/apjon. apjon_13_20. Coomber, B. and Barriball, K.L. (2007) ‘Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: A review of the research literature’, International Journal of Nursing Studies, 44 (2), pp. 297–314. Crawley, H. and Hagen-Zanker, J. (2018) ‘Deciding where to go: Policies, people and perceptions shaping destination preferences’, International Migration, 57 (1), pp. 20– 35. doi:10.1111/imig.12357. Department of Statistics Singapore (2021) ‘Population and population structure’. Available at: https://www.singstat.gov.sg/find-data/search-by-theme/population/populationand-population-structure/latest-data (Accessed: 15 October 2021). Goh, Y. and Lopez, V. (2016) ‘Job satisfaction, work environment and intention to leave among migrant nurses working in a publicly funded tertiary hospital’. Journal of Nursing Management, 24 (7), pp. 893–901, doi:10.1111/jonm.12395. Humphries, N., Brugha, R. and McGee, H. (2009) ‘“I won’t be staying here for long”: A qualitative study on the retention of migrant nurses in Ireland’. Human Resources for Health, 7 (68), doi:10.1186/1478-4491-7-68. ICA – Immigration and Checkpoints Authority of Singapore (2021) ‘Becoming a permanent resident’. Available at: https://www.ica.gov.sg/reside/PR/apply (Accessed: 15 July 2021). Immigration Services Agency of Japan (2022) ‘Support website for the Specified Skilled Worker Program’. Available at: https://www.ssw.go.jp/en/about/howtowork/ (Accessed: 5 October 2022). Khalik, S. (2016) ‘Thirty thousand more healthcare workers needed by 2020 to cater for Singapore’s ageing population: Health Ministry’. The Straits Times. 20 October 2016. Available at: http://www.straitstimes.com/singapore/health/30000-more-hea lthcare-workers-needed-by-2020-to-cater-for-singapores-ageing (Accessed: 7 February 2018).

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Kingma, M. (2008) ‘Nurses on the move: Historical perspective and current issues’, OJIN: The Online Journal of Issues in Nursing, 13 (2), Manuscript 1, doi:10.3912/ OJIN.Vol13No02Man01. Lai, L. (2014a) ‘More benefits rolled out for nurses in the public sector’, The Straits Times, 6 August. Available at: https://www.straitstimes.com/singapore/more-benefitsrolled-out-for-nurses-in-the-public-sector (Accessed: 20 July 2020). Lai, L. (2014b) ‘Some Singapore nurses find work “too hectic”’, The Straits Times, 9 August. Available at: https://www.straitstimes.com/singapore/some-singapore-nursesfind-work-too-hectic (Accessed on 20 July 2020). Lien Foundation (2018) Long-term care manpower study. Available at: http://www.lien foundation.org/sites/default/files/Long%20Term%20Care%20Manpower%20Study% 20FINAL_0.pdf (Accessed: 15 September 2020). Matsuno, A. (2009) ‘Nurse migration: The Asian perspective. ILO/EU Asian programme on the governance of labour migration: Technical Note’. Bangkok: International Labour Organization. Available at: http://www.ilo.int/wcmsp5/groups/ public/—asia/—ro-bangkok/documents/publication/wcms_160629.pdf (Accessed: 15 September 2020). MOM – Ministry of Manpower, Singapore (2021a) ‘S-pass quota and levy requirements’. Available at: https://www.mom.gov.sg/passes-and-permits/s-pass/quota-and-levy/levy-a nd-quota-requirements (Accessed: 5 October 2021). MOM – Ministry of Manpower, Singapore (2021b) ‘Passes for family of employment pass holders’. Available at: https://www.mom.gov.sg/passes-and-permits/employm ent-pass/passes-for-family (Accessed: 10 October 2021). MOM – Ministry of Manpower, Singapore (2021c) ‘Occupational wages 2020’. Available at https://stats.mom.gov.sg/Pages/Occupational-Wages-Tables2020.aspx (Accessed: 10 October 2021). Nemes, S., Jonasson, J.M., Genell, A., and Steineck, G. (2009) ‘Bias in odds ratios by logistic regression modelling and sample size’, BMC Medical Research Methodology 9 (56). doi:10.1186/1471-2288-9-56. Oda, H. (2018) ‘An analysis of Indian nurses’ intention to migrate abroad’, in Y. Tsujita, Institute of Developing Economies Report on The international migration of nurses: Comparison between the Philippines and India, pp. 23–40. Available at: https://www.ide. go.jp/library/Japanese/Publish/Reports/InterimReport/2017/pdf/2017_2_40_007_ch02. pdf (Accessed: 10 October 2021). OECD – Organization for Economic Cooperation and Development (2019) Remuneration of nurses. Health at a glance 2019: OECD Indicators. Paris: OECD Publishing. doi:10.1787/4dd50c09-en. Paul, A.M. (2011) ‘Stepwise international migration: A multistage migration pattern for the aspiring migrant’, American Journal of Sociology, 116 (6), pp. 1842–1886. Schober, M. (2013) Factors influencing the development of advanced practice nursing in Singapore. Doctoral thesis. Sheffield Hallam University, Sheffield Hallam University Archives. Available at: http://shura.shu.ac.uk/7799/ (Accessed: 10 September 2021). Schwartz, A. (1976) ‘Migration, age, and education’, Journal of Political Economy, 84 (4, Part 1), pp. 701–720. Sin, Y. (2020) ‘Parliament: Annual number of new PRs and citizens stable for last 5 years, says Indranee’. The Straits Times, 14 October. Available at: https://www.stra itstimes.com/singapore/politics/parliament-annual-number-of-new-prs-and-citizensstable-for-last-5-years-says (Accessed: 20 October 2020).

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SNB – Singapore Nursing Board (2021). Various years. SNB Annual report. Available at: http://www.healthprofessionals.gov.sg/content/hprof/snb/en/topnav/publications_ forms/publications.html (Accessed: 15 March 2021). SingHealth (2019) Nursing in SingHealth. Available at: https://www.singhealth.com.sg/ DoctorsAndHealthcareProfessionals/Nursing/Nursing/Pages/Home.aspx (Accessed: 15 March 2019). Toyota, M. (2012) ‘Guarded globalisation: The politics of skill recognition on migrant health care workers’, in D. Haines, K. Yamanaka et al. (eds.), Wind over Water: Migration in an East Asian Context, pp. 229–240. USA: Berghahn Books. Tsujita, Y. and Oda, H. (2018) ‘International migration of Indian nurses at the place of origin and the destination’, in Y. Tsujita (ed.) Human Resource Development, Employment and Mobility of Healthcare Professionals in Southeast Asia: The Case of Nurses in IDE-JETRO BRC (Bangkok Research Centre) Research Report. Available at: https://www.ide.go.jp/English/Publish/Download/Brc/22.html (Accessed: 10 December 2018). Wong, L. (2016) ‘Elderly sick turn to foreign, live-in caregivers’. The Straits Times. 27 December. Available at: http://www.straitstimes.com/singapore/health/elderly-sick-turnto-foreign-live-in-caregivers (Accessed: 19 March 2018). WHO – World Health Organization. (2020) ‘Nursing and midwifery’. Available at: https://www.who.int/news-room/fact-sheets/detail/nursing-and-midwifery (Accessed: 10 October 2021).

Appendix Descriptive statistics of respondents (n=264) Type of setting

n

(%)

General or specialty hospitals

159

60.23%

Others

105

39.77%

Total

264

100.00%

Type of facility

n

(%)

Privately funded

149

56.44%

Publicly funded

115

43.56%

Total

264

100.00%

Gender

n

(%)

Female

136

51.52%

Male

125

No answer Total

3 264

47.35% 1.14% 100.00%

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Maria Reinaruth D. Carlos

Marital status

n 58

21.97%

201

76.14%

Married Single

(%)

5

No answer

1.89%

Total

264

100.00%

Current Occupation

n

(%)

RN

114

43.18%

EN

62

23.48%

NA/HCA

88

33.33%

264

100.00%

Total Years since graduation

n

(%)

Years working in Singapore

n

(%)

~ 3 years

21

7.95%

~ 3 years

111

42.05%

~ 6 years

56

21.21%

~ 6 years

92

34.85%

~ 9 years

105

39.77%

~ 9 years

34

12.88%

~ 12 years

50

18.94%

~ 12 years

8

3.03%

~15 years

11

4.17%

~15 years

4

1.52%

~ 18 years

9

3.41%

~ 18 years

1

0.38%

~ 21 years

4

1.52%

~ 21 years

1

0.38%

~ 24 years

4

1.52%

No answer

13

4.92%

4

1.52%

Total

No answer Total

264

100.00%

264

100.00%

5

From Nurses to Care Workers Deskilling among Filipino Nurses in Japan Katrina S. Navallo1

Introduction What is the use of having a [nursing] license if you are unable to reap the benefits of the profession…You want to continue being a nurse and yet, [there are no jobs] you are not financially supported [by it], it doesn’t have any meaning. That is why, I am here, I have decided to work in Japan [as a care worker]. (Rosemary, 26, interviewed in November 2017)2

Rosemary was among the hopeful Filipino nurses who studied Nihongo (national language of Japan) for a year in the Philippines in the hopes of getting a job in Japan as a care worker. When the author met her in 2016, she had just arrived in Japan to begin a year of further language training then to enrol in a care worker training school. After a year of language study and two years in the care worker training, she successfully passed the care worker licensure examination in 2020 and now is working fulltime at a long-term care facility in Kansai. Despite being a nurse in the Philippines, Rosemary decided to forego her professional status and instead became a care worker in Japan. This chapter discusses professional deskilling of Filipino nurses who become care workers in Japan. In this chapter, skill refers to the set of professional qualifications and competencies gained through formal nursing education and professional experience through employment as nurses (Gotehus 2021). Deskilling is observed in the experiences of migrants who possess a certain level of training, professional and technical skills, but often take up jobs that are below their competencies. Professional nurses regularly figure into the cohort of deskilled labour migrants. The International Organization for Migration (IOM) broadly defines deskilling as performing jobs that are not commensurate with the workers’ education, qualifications, and work experiences and this especially occurs among female migrants in the domestic and care work sector (IOM 2013). Variations in deskilling and downward occupational mobility among nurses have been observed across migrations from low-income countries to more affluent countries. For example, downward mobility within the nursing profession has been observed among migrant nurses who became licensed practical nurses DOI: 10.4324/9781003218449-6

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in Canada (Salami et al. 2018), which reflects a step down from their original training and stature as professional nurses in their home country. However, deskilling in terms of skill mismatch and underemployment is observed among Filipino nurses who become domestic workers in Canada (Pratt 1999; Salami, et al. 2014) and those who become au pairs and care workers in Norway (Gotehus 2021; Korzeniewksa and Erdal 2021). Studies on deskilling have referred to the concepts of “brain drain”, “brain waste”, “downward occupational mobility” (Bauer and Zimmerman 1999), “skill erosion” (Galgoczi et al. 2009), “invisible underemployment” (Flatau et al. 1995), among others, to characterise the variations and complex implications of deskilling not only to the migrants’ occupational mobility, but also to the socio-economic conditions of countries who send labour abroad. As one of the frontliners among the healthcare professions that are engaged in the direct care of individuals, international nurse migration has become enmeshed in the global circulation of care. Existing analytical concepts, such as the global transnationalisation of care offer insights into how migrants become embedded in the circulation of paid care across countries, in a complex network of states’ and markets’ interests and activities that govern their migration and employment. Scholars have discussed this in detail, for example, through the concepts of new international division of reproductive labour (Parreñas 2001), global care chains (Hochschild 2000), global nursing care chain (Yeates 2009), transnational political economy of care (Williams 2014), and transnationalisation of care (Yeates 2011). This chapter contributes to deskilling in nurse migration literature by examining the migration experience of Filipino nurses who become care workers for the elderly in Japan. Situating within the migrant nurses’ experiences of the states’ institutional migration structures in place, it discusses how they negotiate their skills and education in bargaining for jobs overseas to enable and sustain their migration. The succeeding discussion contributes an understanding of deskilling from the nurse migrants’ perspectives including their motivations and experiences as they shift to care work, their struggles at work and desire to return to their profession, and their prospects for further migration after becoming care workers.

Deskilling in international nurse migration In migration studies, deskilling refers to various “instances where human capital, in terms of education and experience, skills and know-how, are not being employed in meaningful and productive ways” (Korzeniewska and Erdal 2021, p.3). The process of deskilling may start before a migrant nurse even leaves her country, prompted by the unpredictable changes and fluctuations in the global demand for nursing jobs. Ortiga (2018, p.173) illustrates this in the case of Filipino nurses who fall into either the “migration trap” when they “obtain specific credentials in the hope of working overseas, yet are unable to leave when labour demands or immigration requirements

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change”; or the “opportunity trap” when they “collect credentials in order to secure a positional advantage in the job market” which do not necessarily add to their chances of being recruited into overseas employment. Because of the competitive and highly selective nature of the nurse recruitment process that often requires a certain number of years of work experience and preference for a nursing specialisation, to name a few, not all nurses are able to meet those criteria. Those who are unable to meet the stringent requirements or who are simply passed over for a more desirable candidate are left with two choices: “find other ways to practice nursing, or leave the profession altogether” (Ortiga 2018, p.181). The latter option is reflected in Rosemary’s narrative at the beginning of this chapter, where she reflects on her decision to accept a care worker job in Japan because her nursing credentials are not enough to allow her to find a nursing job there. At the same time, there are markets for such nurses who are willing to move out of the profession and transition into other occupations that make use of their nursing qualification and skills. The aged care sector in affluent countries provides a viable option for them as care work jobs have proliferated with less stringent qualifications compared to a nursing job. To tap its growing healthcare workforce, the Philippine state has entered into several bilateral agreements with a number of countries for the export of health professionals, including nurses, care workers, physical therapists, occupational therapists, and other healthcare technicians. These countries include Germany, Canada, United Kingdom, Kingdom of Saudi Arabia, Israel, and Japan, among others. The labour agreements entered into by the Philippine government involving selected types of professions encourage the migration of professional and highly skilled Filipinos to other countries. The Philippines’ economic development strategy of exporting labour is well documented (Cabanda 2015; Ortiga 2014;; Guevarra 2010; Masselink and Lee 2010; Rodriguez 2010; Choy 2003). Rodriguez (2010) hails the country as a labour brokerage state in its global enterprise producing “highly-skilled, well-educated, English-speaking” workers. Filipino nurses figure as one of the top labour exports of the Philippines, supplying nurses primarily to the US, Gulf countries, UK, Canada, Australia, among others. Cabanda (2015, p.1) explains that sending states, such as the Philippines, actively mediate health professional migration by introducing “restrictive measures to delay the outmigration of health professionals”, such as the imposition of mandatory years of service for nursing graduates of public schools, while also responding to “market demands by producing and promoting emigration”. Non-state actors, such as nursing schools, licensure exam review centres, and recruitment agencies are also able to shape the licensure and recruitment processes by commercialising nursing education and making it available to diverse groups of students (Masselink and Lee 2010). All these dynamics hew into the current nurse migration system that connects the Philippines to Japan.

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Migration of Filipino nurses to Japan as care workers The aging society in Japan has created increased demand for care workforce. Meanwhile, the embeddedness of labour migration in the Philippine economic development strategy dovetails with the demand for care work in Japan. Currently, there are two pathways for foreign nurse migrants to become care workers in Japan: (1) as care worker candidates under the Economic Partnership Agreement (EPA), and (2) as students enrolled in care worker training school in Japan (so called ‘nursing care’ study). The migration pathways for nurses and care workers are shaped by the politics buttressing Japan’s migration policy that only accepts “highly skilled workers”.3 However, in countries like the Philippines, nurses are considered professionals and highly skilled workers, while care workers (or caregiver) have lower skill levels. Ogawa (2012, p.574) notes that “distinctions between ‘skilled’ and ‘unskilled’ vary based on political decisions within each country” and in the case of Japan, care work, despite being a relatively new occupational category that came about because of the demand of the aging population, is considered highly skilled work that is regulated by a professional body. Among the receiving countries for migrant nurses, Japan has only begun accepting foreign nurses since the beginning of its EPA system with three Southeast Asian countries: Indonesia (2008), Philippines (2009), and Vietnam (2014). From 2009 to 2019, a total of 588 Filipino nurses have entered Japan as “nurse candidates” under the EPA system, just before the COVID19 pandemic halted further entry of foreign nurses to Japan due to the travel ban (MHLW n.d.). The EPA system is the only migration pathway available for foreign nurses to work in Japan, and the acceptance of foreign nurses is currently limited to the three signatory countries. Japan has no established framework for the recognition of foreign nursing qualifications. Therefore, foreign nurses have to undergo training as “nurse candidates” and pass the nurse licensure exam to practice the profession in the country.

State-led migration: Economic Partnership Agreement Both the Japanese and Philippine governments were involved in the crafting of the migration policy that opened the door for Filipino nurses and care workers in Japanese care work labour market. The EPA is essentially a trade in goods and services agreement, but the impetus to include movement of natural persons in the exchange was originally motivated by the Philippine government through then President Arroyo’s proposal to include the acceptance of Filipino domestic workers, nannies, caregivers, and nurses (Asato 2013). This was met by contradictory reactions from both sides. The Japanese Ministry of Health, Labour and Welfare (MHLW) and the Japan Nursing Association were cautious about the acceptance of foreign care workers to protect the interest of the domestic labour market (Ogawa 2012; Ohno 2012), while the Japan Business Federation (Keidanren) in fact welcomed the

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proposal as a means of preparing for the challenges in the impending labour demand of an aging society (Asato 2013).4 Various concerns about the inclusion of foreign nurses and care workers in the Japanese care sector have been regarded as potentially lowering the standards of care due to differences in educational qualification and training of foreign health professionals, and possibly demotivating the local care workforce as the entry of migrant care workers could undermine the Japanese nursing profession (Ogawa 2012). These reactions were strongly voiced out during the initial years of the EPA implementation. With regards to the candidates’ qualifications and skills, the Japanese and Philippine governments negotiated on the minimum standards for nurses and care workers as set by their respective professional associations. For nurse candidates, these include the following criteria: (1) graduate of a nursing degree, (2) with valid nursing license in the Philippines, and (3) with at least three years of hospital experience. The years of work experience was meant to compensate for the difference in the total number of years of schooling in the Philippines, which is short of one year compared to Japan. Meanwhile, the requirements for care worker candidates are set as follows: (1) a graduate of any four-year college course and certified caregiver by the Technical Education and Skills Development Academy (TESDA) in the Philippines, or (2) a graduate of nursing course (POEA Circular No. 03, 2009) with or without national license and work experience. The Philippine Overseas Employment Agency (POEA) and the Japan International Corporation of Welfare Services (JICWELS) were in charge of the recruitment and management of nurses and care workers from the Philippines to Japan. From the Philippine side, the EPA recruitment of nurses was heavily opposed by the Philippine Nursing Association (PNA). In three position papers released in 2010 and 2011, they view that the structure of the EPA sees Filipino nurses as “cheap labour” by treating them as trainees for three years when their qualifications already meet the professional standard.5 The opposition by PNA was originally directed against the nurse recruitment process, but since then, the recruitment of nurses as care workers was also opposed by the PNA as inappropriate treatment of Filipino nurse professionals.6 The POEA requirement for nurse candidates is at least three years of hospital work experience, and many trained nurses who do not meet this criterion are offered the option to apply as care workers. Those who fail to satisfy the nursing requirements often seek other options and some apply as care workers instead. Such is the case of Lisa, a Filipina registered nurse who became an EPA care worker candidate in 2009: It’s timely that the POEA offered me a work. I have an application in Saudi as a nurse, but when the POEA called me, “Do you want to fill-in because there’s some [EPA] applicants who are backing out?” Or, uh, you know, their requirement is not good, so they asked me if I want to take the chance. But not [as a] nurse because I don’t have three years of

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Katrina S. Navallo experience in the hospital. So, if I want to be a caregiver in Japan, they will allow me to apply. Comparing from Saudi Arabia to Japan, I chose Japan…Even if it’s not my first priority, you know – I want to be a nurse, no? But it’s okay. So, I took the chance. (Lisa, 39, interviewed in November 2017)

Selective preference is present in the recruitment process for nurses, effectively leaving out many nurses with inadequate work experience either as care workers, or who find jobs in other countries with lower requirements. The distinction between licensed nurses with significant hospital work experience and nursing graduates without work experience effectively segregates who can migrate as nurses from those who do not meet these minimum requirements and are left behind.

Market-led migration: Care work study On the other hand, other non-EPA pathways for Filipino nurses include the care work study. Since care work training schools require a high level of Japanese language proficiency, prospective foreign care workers have to study the language first. This process begins in the Philippines, where Japanese language institutes recruit potential candidates under a language “scholarship” programme, which is actually a study now, pay later scheme. Most of these institutes are tied with recruitment agencies deploying workers for Japan. Nurses are often targeted, as they are seen as already having the medical knowledge and training for care work. Once they are recruited, they receive Japanese language training for three to six months, and assistance in arranging for their entry to Japan through the foreign student (ryuugakusei) visa. Upon reaching Japan, they commence their Japanese language course in a language school and satisfy the language requirement of N27 to further enrol in care work training schools. The costs of coming to Japan through this pathway are high and training/ recruitment agencies in the Philippines take advantage of this by promoting schemes that help in the placement of prospective migrants in language schools in Japan. The programme is marketed as a scholarship (study-nowpay-later) with work opportunity (exploiting the 28 hours a week of allowed part time work). The applicants are required to pay the cost of one year of language programme, amounting to JPY600,000 (roughly US$5500 or PHP290,000)8 besides the recruitment and departure fees, which total about one million JPY at the time of their departure (Carlos and Suzuki 2020). To supplement the remaining costs, recruitment agencies introduce them to Japanese employers where they can work part-time to earn their payment for the remaining matriculation fees for the rest of the language programme. As an example, Rosemary and Leonora arrived in Japan in July 2016 after more than a year’s effort of learning the Japanese language under the recruitment programme for nurses operated by a training/recruitment agency

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in the Philippines. They paid about PHP50,000 (approximately JPY100,000) for the one-year language training. Towards the end of their language training, only three out of about 20 applicants passed the evaluations and were trained as care workers in Japan. They arrived in Japan with a ryugakusei visa, where they had a further six months of language training. After finishing the language course, they decided to proceed to care work study under a scholarship programme from the local prefectural government applied to on their behalf by their Japanese employer. While studying, their employer allowed them to work as part-time care workers in the care facility for a maximum of 28 hours a week. They were paid JPY856 per hour which was the going rate for care workers at that time. The accumulated salary, which amounts to about JPY60,000 per month was what they used for their monthly expenses, such as allowance and transportation, while their employer subsidized their housing rent. Once they completed the two-year care work training, they were required to take the exam and pass it in order to secure their stay in Japan as certified care workers (kaigofukushishi) and continue working in the employing facility.

Other migration pathways for non-nurses to work in Japan as care workers The number of care workers coming from the Philippines to Japan are expected to increase to 60,000 with the inclusion of “care work” in the occupations under the Special Skilled Work which was introduced by the Japanese government in 2019 (Department of Labor and Employment, Philippines 2019). All these hews to the projected need for an additional 380,000 care workers in Japan by 2025 according to the MHLW (Hirano 2018). However, while Filipino nurses are seen as desirable candidates for care work given their professional background, recruitment of care workers is not restricted to nurses alone. Graduates of caregiving courses and other four-year college courses are allowed to apply given that they satisfy the requirements. Other care worker migration pathways for non-nurses include the specified skilled worker visa and technical intern trainee system. The qualifications for the specified skilled worker visa include the following: (1) must be at least 18 years of age, (2) passed the computer-based test on nursing care skills and (3) has Japanese language. Meanwhile, the technical intern trainee system has recently included “care work” under the accepted occupations and provided another migration pathway for aspiring care workers. The qualifications for care worker technical intern trainees include: (1) at least, one year work experience in caregiving or related work, or (2) if without work experience, must have a Caregiving National Competency Level II certificate from TESDA, or a completed four-year healthcare related degree course, and (3) must have N4 level of JLPT or other equivalent exams.9 Table 5.1 shows a comparison of the requirements for nurses who enter Japan as care workers depending on each migration pathway.

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Table 5.1 Migration pathways for Filipino nurses and non-nurses to enter Japan as care workers Migration pathway

Educational background

Professional qualification

Years of work experience

Recruitment

Fees and other migration costs

EPA

Graduate of nursing or related course, or graduate of caregiving course

Not necessary

Government (Philippine Overseas Employment Agency)

None

Student of care worker training school (Nursing care) Technical Intern Trainee

Not specified, usually at least graduate of high school

Has government certification as care worker in home country (NC II in Caregiving from TESDA) Not necessary

Not necessary

At least one-year work experience as care worker or in similar profession

Cost of enrolment fees, airfare, accommodation, and recruitment agency fee None

Special Skilled Worker**

Not specified

Has government certification as care worker in home country (NC II in Caregiving from TESDA) Not specified, but has to pass the computerbased Nursing Care Skills Evaluation Test

Market sector: language institutes and recruitment agencies Government and market sector: Sending organizations

Government: Individual application

None

Graduate of caregiving training course; or graduate of any 4-year healthcare related course

Not specified

Table created by the author based on the data from the following sources: Mizuho UFJ Research and Consulting Co. Ltd. (2019), Department of Labour and Employment, Philippines (2019). **At the time of writing, this scheme has just started and no informants under this pathway have been included in the study.

At the initial stages of the EPA implementation, Asato (2012) argued that the participation of foreign nurses in the Japanese labour market creates a dual labour market. In recent years, the nursing care study route has also accepted the entry of Filipino care workers who come to Japan to study care

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work, and this pathway is less regulated than the EPA. The availability of foreign care workers who are willing to enter into work contracts without the stringent requirements (typically imposed by the EPA on employing institutions) may contribute to the creation of a secondary labour market that receives much less regulation and is subject to exploitation. This contributes to the deskilling experienced by Filipino nurses who had to compete with other care workers with lower training and qualifications.

Methodology A total of 32 interviews were conducted, including ten nurses in Manila and 22 nurses who were training and working as care workers in Japan from 2017 to 2019.10 The interviews were part of a larger doctoral ethnographic project.11 In addition, an intensive one-month participant observation was conducted in a care facility in Kyushu, the southern region of Japan in 2019, where the author accompanied Filipino care workers in their eight-hour shifts five times a week over one month as a volunteer. Permission was sought from the director of the care facility to work as a volunteer for the doctoral project. In the Philippines, the author established connections with three language training institutes in Metro Manila who were accepting nurse applicants for care work study and technical intern training in Japan. Permission from the manager of the training school was sought to observe in the classes and to conduct recorded audio interviews with applicants who were interested in coming to Japan as care workers. In Japan, the author sought Filipino care workers through the network of Filipino migrant communities in the Kansai region. Using snowball sampling, the author identified and interviewed Filipino care workers. Permission from the interviewees was also sought to conduct recorded audio interviews. The interviews were conducted in a mix of Tagalog, English, and Japanese languages, and transcribed verbatim. Important and resurfacing keywords in interviews were selected and coded into themes. The author verified the significance of these keywords through their recurrence in the conversations with the Filipino care workers in the study.

Structural constraints that drive deskilling Angel was a registered nurse in the Philippines before moving to Japan in 2012 as an EPA care worker. She graduated and obtained her nursing license in 2010 and worked as a staff nurse for less than two years in a public hospital in the province. Since she did not meet the minimum requirement for EPA nurse candidates to have a three-year work experience, she decided to apply as a care worker instead. Even then her application was denied. At that time, it was stipulated in the memorandum that only graduates of nursing courses (excluding licensed nurses) were accepted for care work. When she decided to resubmit her application as care worker next time, she did not declare that she

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was a licensed nurse, and only submitted a nursing diploma. This time, her application was successful and she was able to depart for Japan in 2012. On the other hand, many of non-EPA informants such as Rosemary and Leonora mentioned earlier, said that they were not aware of the EPA programme, and instead came across the language training programme that would allow them to go to Japan as care workers. The difficulty of finding nursing work in the Philippines is reflected in both women’s experiences. Rosemary’s first work was in a call centre for less than six months. Afterwards, she became a volunteer nurse in a hospital for three months, where she was not paid. Most hospitals accept volunteer nurses without pay, and they can gain hospital clinical experience and include it in their resumes. Working abroad as a nurse requires substantial hospital work experience, which becomes difficult to acquire due to the lack of employment opportunities in Philippine hospitals (both public and private) due to limited available nursing positions. Moreover, the huge disparity in the incomes of nurses in the private and public health sectors in the Philippines also present unequal opportunities for Filipino nurses, as positions in government hospitals are limited and politically governed by those who know someone from within the institution. This issue further deepens the underemployment of nursing graduates and drives the migration of nurses abroad who seek better wages and work opportunities than they can find in the Philippines. Because of the lack of professional opportunity, many nursing graduates instead find work in other sectors, such as the business process outsourcing (BPO) and call centre industries, which provide a relatively higher salary than regular hospital nursing jobs, private duty nursing, public community nursing, pharmaceutical work, teaching, and other jobs. There is a perception in the Philippines that those who engage in non-hospital work, such as nursing homes, school clinics, and even rural health units are less skilled because of the lack of opportunity to practice advanced-level clinical skills and develop competency in a specialised nursing field, which is attractive for and oftentimes required by employers abroad. That is why with the opening of care work in Japan, those Filipino nurses lacking in hospital experience, see this as an opportunity to gain a healthcare-related (albeit non-nursing) work experience in a developed country, which they can eventually leverage as medical work experience. Of the 21 registered nurses among informants in Japan, only four had relevant hospital work experience before coming to Japan. The rest were involved in private duty nursing, community nursing, non-governmental organisation work, BPO, and other jobs. Despite the potential deskilling and downward mobility in becoming care workers, nurse applicants from the Philippines reconfigure their qualifications in order to migrate internationally. For those who went through the state-led migration service, Lisa and Angel’s stories reflect how migrants work around the institutional structures that govern their migration by not declaring their professional status. For Rosemary and Leonora who went through the market-led migration, they also had to satisfy the requirements by enrolling in

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the care work study programme. In both instances, nurse migrants intentionally configure their qualifications to suit the requirements of the migration policies to successfully migrate at the cost of downward professional mobility in their nursing careers. While many would want to take the established route, in most cases migrants do not always satisfy the minimum entry requirements of certain migration pathways. Most of informants decided to do so even if it meant accepting a job that is below their skills. However, as will be discussed in the following sections, the complex impacts of such a decision are only fully realised once they work in their new role as care workers.

Transitioning from nurses to care workers: De-valuation of nursing skills When Rosemary began a care work job in Japan, the first issue she had to deal with was the difference in the roles and responsibilities as a care worker compared to a nurse. In Japan, care workers have limitations in the provision of certain tasks that require proper training certification, such as nail cutting, massaging, suctioning, and treating bed sores. For example, nail cutting which is considered a common nursing care, requires certification for care workers, as it is not part of their training. This difference in the expected work of care workers was expressed concretely by Rosemary: For example, they want to have their nails cut, back home [in the Philippines] it is a normal [nursing care], but in Japan the rules are different. The boundaries of what caregivers with and without license can do are different. Cutting of nails are done by nurses or trained caregivers only. So, during times when residents ask me to cut their nails, I have to decline because I am not allowed…So that is one thing that new care workers have to take into consideration, the limits of the professional conduct. (interviewed in November 2017) Professional standards guide and regulate the quality of care and this includes care workers understanding and maintaining their professional limitations. Filipino care workers learn the standards of professional care work in Japan, and they also have to forego using certain nursing skills which are not part of their role; otherwise they have to undergo additional skill training and get certified, which costs money and time. Other limitations include the care of bed sores, which are only allowed for nurses to treat, and suctioning the respiratory tract in cases when residents have a lot of mucus. In nursing, suctioning as well as feeding through a naso-gastric tube are nursing procedures that are considered as basic skills, but these are considered specialised skills requiring specialist training for care workers. Another example is back massage, considered a nursing intervention for relieving anxiety and stress, which is only allowed for licensed physical therapists in Japan and cannot be given by care workers.

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Israel, who has 10 years of working experience as a hospital nurse in the Philippines, was assisting an elderly resident eating in a care home in Japan. In one instance, while one of the residents was being fed, he started to cough showing signs of possible choking.12 At that time there was no one on the unit except him and another Filipino care worker, and while care workers who have been trained in first aid response could attend to such cases, as a trainee, he is expected to call the nurse for any emergency. This resident of ours, doesn’t seem to have a very good swallowing reflex. That’s why there was an instance that he choked on his food. Everyone was in a state of urgency. I noticed that his colour was changing…his pupils were dilated…I told myself this is bad…I observed first if he was really choking or it could be something else, until I saw that his colour was changing. I told another Filipino shokuin [care staff member] to call the nurse, and I was the only one left with the resident. Then, I did the Heimlich [maneuver]. When the nurse arrived, the resident had been able to expel the food. (Israel, 35, interviewed in June 2018) He called the nurse, but as he was seeing the elderly’s face turning blue, he immediately stood behind the resident and performed a Heimlich maneuver, which is an upward thrust on the abdomen to dislodge the food from the esophagus. The elderly resident was able to bring out the food particle and recovered afterwards. It was fortunate that Israel knew how to respond appropriately in such an emergency situation because of his training as a nurse. Ordinarily care workers without proper first aid training would not have been able to respond to this situation, and professional standards would dictate him/her to relay to the nurse.

Boundaries and pressures of care work in Japan Informants with a nursing background felt that they had more knowledge than regular care workers when it came to physiological conditions, medical illnesses, and nursing procedures. This knowledge can come in handy, especially in emergency situations. Being trained in such, they are able to easily identify changes in physical conditions of the residents. [With our nursing background] we feel advanced in terms of assessing what is normal and what is not, we’re the first to see it [compared to other care workers]. (Leonora, 26, Interviewed in November 2017) Despite having medical theoretical knowledge, their performance at work is significantly influenced by the level of their language ability, which is crucial in communicating with the residents and co-workers, carrying out orders, and

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documenting their care. Language barriers become a concrete hindrance in performing at a level that they deem at par with their training and skills as professional nurses and lead to feelings of incompetence and professional frustration, as expressed by Lisa: Maybe because I’m a kangoshi, [a nurse] in the Philippines. So, I have some knowledge in the medical and nursing field. But I don’t have experience in the hospital. So, I just came here for caregiver work, for assistance only…We can give medicines to the patients with the supervision of the nurses…Definitely, our main duty is to change diaper, assist them in bathing…food preparation, and meal assistance, and then, their daily activities. That’s the main duty of a caregiver here. So, it doesn’t matter if you’re a nurse in the Philippines. If you’re a caregiver here, your work is caregiving. (Lisa, 39, Interview in November 2017) While Filipino nurses understand the need to be certified as a care worker in order to practice the care work profession in Japan, many perceive those three years of training as a care worker as very limiting in terms of what they can and are allowed to do. Lisa shares her thoughts on this prolonged training period in the EPA programme: At first, we just observe [the procedures done by certified care workers] for three years…and then, after the exam, then that’s the time they will teach us [to do the actual care tasks by ourselves]. (Interviewed in November 2017) The downward mobility is most apparent in the limited tasks and responsibilities of a care worker compared to a nurse, who engages in nursing and caring procedures. Care workers are mostly involved in the physical care and upkeep of the body, such as providing assistances in toileting, eating, walking, changing diapers, that extend to non-medical care, such as cleaning the residents’ rooms and toilets, disposing of garbage, laundering the residents’ clothes and sheets. Rosemary ponders on her realisation of her downward professional mobility from being a nurse in the Philippines to a care worker in Japan: At first, it felt, in a way, degrading. Of course, I graduated with a nursing degree, and then at some point it makes you think, was it a waste of my education? That I am not using it? But it’s your mindset, your decision if you think it’s a waste…Although now, we are not fully independent at work since we are still students, trainees. There are boundaries and restrictions in what we are allowed to do…Like I said, there are restrictions. (Interviewed in November 2017)

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In addition, since they are engaged in frequent body care, the care tasks put a strain on care workers’ bodies. This further contributes to the unattractiveness of care work and many see that it is not a lifetime job, in addition to the limitations of care work as a career: It’s really hard work. You need to lift them up, you know? You need to transfer them from bed to wheelchair, transfer them for six times a day… and then assist in bathing. Not only in bathing, because they cannot… move at all, so, you need to lift them up…You really need energy. (Lisa, 39, interviewed in November 2017) This also rationalises the bodily component of care work as something that is not desirable. As nurses who are trained in the “profession”, the image of doing bodily care is regarded as the responsibility of novices with less experience. As one moves up the hierarchy and gains proficiency and expertise through the years, the responsibilities move away from direct body care to tasks that involve intellectual activities, including management and leadership roles. The acquisition of skills from basic to more complex procedures parallels the time that care workers are doing the same tasks. However, the limitations of care work prevent them from accruing more specialised tasks unless they undertake specific training. At the same time, the demands of care work itself limits them to the activities they are expected to do.

Opportunities and limitations of the EPA programme About the permanent residency for EPA care workers…it’s very hard… [even if] we passed the exam. But in the back of my mind, they [the government] don’t want you to be a permanent resident because if you became a permanent resident, you will get another [non-care work] job. And you will not stay on as a care worker…And they have a shortage of care workers…As EPA care worker, our visa is for designated activities. You only do the care giving job. Because if the foreign worker took a permanent resident, you know, right away they will change jobs. (Lisa, 39, Interviewed in November 2017)

Lisa’s sentiment reflects the glaring problem that the whole EPA programme as a labour agreement is founded on Japan’s migration policy. Since their occupations (current positions) are tied to their visa statuses, they are tied to one occupation for the rest of their stay in Japan. Shifting to nursing is virtually impossible with the type of visa they hold as care workers in Japan. This is a major frustration for qualified nurses who eventually find care work as a dead-end job. Aside from this, care workers continue to receive a relatively low salary compared to other blue-collar occupations in Japan. Their gross monthly salary reaches about JPY200,000 but tax, pension, health insurance, housing, utilities, and living-expenses deductions leave them with

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very little to save or remit back to their families in the Philippines. Four of this study’s informants with children in the Philippines informed that it is impossible to bring their families to Japan with their meagre income. In addition, the challenge of learning a new language and culture especially for children at school is a huge burden if their whole family is to migrate to Japan. Even with the ability to bring dependents, many chose to have their children and families stay in the Philippines where they can send monthly remittance and be assured that someone in the family can properly look after them. As a result, a lot of EPA candidates did not complete the programme and went back to the Philippines or moved elsewhere, prompting Hirano (2018) to call it a failed “policy without a vision”. It is often the case that care work in Japan serves as a springboard or a transit stop for those who want to pursue itinerant migration to other more desirable countries. Carlos (2013) refers to this sense of mobility among Filipino professional nurses as multi-step migration and is also seen among other Filipino migrants such as domestic workers in Singapore (Paul 2015). Due to the implications of their deskilling, many of this study’s nurse informants have plans to eventually leave Japan, seek opportunities elsewhere, and explore their return to the nursing profession. Most of them are young and can afford to move to other more desirable jobs either in Japan or elsewhere, and more desirable jobs mean the ability to apply for permanent residence and citizenship, which will allow them to receive full welfare benefits in the host country and perhaps reunite with their families. For nurses, the limited career prospects for care workers in Japan drive them to look for better work opportunities in other countries or back in the Philippines. Three of the study participants have already left Japan: one went back to the Philippines and found a job in Japanese translation in a BPO, while two have gone to the US and Canada to do care work jobs. All three have passed the certification exam for care workers and were granted the special designated long-term status for care workers, however, they still decided to move elsewhere. To be honest, because of the high physical demand and requirements of care work, I would like to continue studying and become a nurse here in Japan. (Rosemary, 26, Interview in November 2017) Despite Rosemary’s desire to practice the nursing profession in Japan, the transition back to the nursing profession is not easy. Filipino nurses who became care workers find it almost impossible to shift back to nursing due to the professional requirements of the nursing profession in Japan and other countries and the nature of their visa status which restricts them only to care work related activities. This is also found among the Filipino nurses who moved to Canada as caregivers, and experienced a significant downward professional mobility (Banerjee et al. 2018). Pratt (1997) argues that the

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prolonged years of non-nursing work could make it “more difficult to recover a previous professional identity”. The work experience they gained in Japan as care workers internationalises their careers even though if not as nurses. Moreover, the credentials they gained in Japan as care workers will not be recognised as nursing work experience in other countries, and many of them utilise their educational credentials from the Philippines when applying for nursing jobs elsewhere. The only advantage according to the informants is that spending three to five years working in Japan is regarded as better than staying in the Philippines, in terms of earning a higher income and gaining work experience abroad. For many informants, care work in Japan helped to internationalise their professional and personal aspirations as the standard of care practice in Japan is comparable to that of other affluent countries which they can leverage in their resume.

Discussion and conclusion This chapter has analysed how Filipino nurses who transitioned to care work jobs in Japan experienced deskilling. It showed how the two countries’ state- and market-led migration of nurses and care workers have structured the available migration pathways for nurses and care workers. The present developments in the migration system of care workers from the Philippines show a hierarchical stratification of care workers according to their educational and technical qualifications. This is problematic when they arrive in Japan, since they will be practically engaged in the care work, but their length of stay, salary, and occupational limitations vary according to the provisions of their visa status. While many migrant nurses would consider the legitimate route, not everyone could satisfy the requirements of the available migration pathways. These requirements segregate nurse migrants, only allowing the “desirable” migrants who meet the minimum qualifications to pass through the selective barriers of migration established by both the sending and receiving states. This selectivity continues to influence their stay in the receiving country. EPA candidates, while bearing the highest requirements, are limited to a maximum of four years of stay in Japan, unless they pass the exceedingly challenging professional certification exam in Japanese language which allows them to extend and renew their stay for up to five more years. Foreign students, on the other hand, do not go through the same stringent selection process but need to demonstrate financial capital in order to finance the cost of language and care worker education and living in Japan while studying there. Similar to the EPA candidates, they are subjected to the care worker certification requirement, which will allow them to stay in Japan as care workers on a semi-permanent basis. The study informants found that while their nursing background proved helpful in identifying potential physiological problems in the elderly residents they care for, the ability to use their nursing skills is limited as the care work

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role restricts their professional responsibilities. Moreover, the career progression in care work is limited to its scope in care management. For those who have nursing background, this can become a cause of demotivation and tension at work, as their abilities are reduced to following the professional limits of care work that are less than or very different from what they were originally trained for in the home country. Despite knowing such risks when shifting into care work, they soon found a sense of frustration when they realised the limited scope of the care work profession. Their motivation to migrate as a care worker in Japan now becomes a stepping-stone for further migration, since emigrating as a nurse from the Philippines is a lot harder. Deskilling is also found among Filipino migrants in the US, Canada, UK, and Australia, and other destinations where they do work that is below their actual educational and skill qualifications. However, unlike other destination countries, applying for permanent residency and citizenship in Japan takes a much longer time and effort; working in Japan as care workers merely serves as the first step towards internationalising their careers and gaining experience in a developed country. These factors largely shape their migration trajectory, that is whether to continue working as care workers in Japan, or to find professional opportunities elsewhere. This chapter offers an understanding of deskilling among migrant nurses and opens further discussion on the career progression of nurses who shift into lesser skilled occupations, and how they navigate the complex dynamics of international nurse migration.

Notes 1 The views and opinions expressed in this chapter belong solely to the author and do not represent the views or position of the organisation. Any errors or omissions are credited to the author. 2 All names of persons and places in this chapter have been changed or anonymized (where appropriate) to maintain and protect their identity. 3 In the Philippines, care worker or caregiver is considered a vocational/technical occupation and is not considered highly skilled work. 4 The positions of the four Japanese Ministries that crafted the policy are the following: Ministry of Economics and Trade and the Ministry of Foreign Affairs are both in favour of labour migration, the Ministry of Justice is not in opposition as long as it is in alignment with the existing immigration control framework, while the Ministry of Health, Labour and Welfare which became in charge of the EPAs later maintained a “cautious stance” (Asato 2013, p.67). 5 Philippine Nurses Association’s Position (2010) the plight of Filipino Nurses under JPEPA Implementation. August 23. https://www.pna-ph.org/component/attachm ents/download/251 Accessed: 9 September 2019. 6 Philippine Nurses Association’s Position Paper (nd) Filipino Nurses as Caregivers/ Care Workers in Japan. Accessed: 10 September 2019. https://www.pna-ph.org/ component/attachments/download/280 7 According to the Japanese Language Proficiency Test, N2 level includes “the ability to understand Japanese used in everyday situations, and in a variety of circumstances to a certain degree” (https://www.jlpt.jp/e/about/levelsummary.html).

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8 In comparison, the average monthly salary of entry-level nurses in the private sector starts at PHP8,000 (Philippine Bureau of Local Employment) to PHP33,500 for those employed in the public sector (based on the recent amendment to the Philippine Nursing Act of 2002). The initial amount needed by aspiring nurse applicants to pay for their Nihongo study in Japan is equivalent to more than their annual income’s worth. 9 According to the Japanese Language Proficiency Test, N4 level means the ability to understand basic Japanese (https://www.jlpt.jp/e/about/levelsummary.html). 10 The 32 interviewees are around 25 to 35 years old, 21 are licensed nurses and 11 are nursing graduates, 15 are unmarried and have no child dependents, and 4 have child dependents. 11 Navallo, K. (2020) “Paid to care: The ethnography of body, empathy and reciprocity in care work among Filipinos in Japan”, Kyoto University, March 2020. 12 In long-term care facilities, most residents who need very high levels of care are at higher risk of choking due to weakened oral muscles.

References Asato, W. (2012) ‘Nurses from abroad and the formation of a dual labour market in Japan’, Southeast Asian Studies, 49 (4), pp. 652–669. Asato, W. (2013) ‘Internationalization of care and harmonization of skills beyond national borders’, Journal of Intimate and Public Spheres 2 (1), pp. 65–81. Banerjee, R., Kelly, P., Tungohan, E., Cleto, P., de Leon, C., Garcia, M., Luciano, M., Palmaria, C. and Sorio, C. (2018) ‘From “migrant” to “citizen”: Labor market integration of former live-in caregivers in Canada,’ ILR Review, 71 (4), pp. 908–936. Bauer, T.K. and Zimmerman, K.F. (1999) ‘Occupational mobility of ethnic migrants’, Institute for the Study of Labor Discussion Paper No. 58. Cabanda, E. (2015) ‘Identifying the role of the sending state in the emigration of health professionals: A review of the empirical literature’, Migration and Development. doi:10.1080/21632324.2015.1123838. Carlos, M.R.D. (2013) ‘The stepwise international migration of Filipino nurses and its policy implications for their retention in Japan’, Working Paper Series, Studies on Multicultural Societies No. 23. Kyoto: Afrasian Research Centre, Ryukoku University. Carlos, M.R.D. and Suzuki, Y. (2020) ‘Japan’s kaigoryugaku scheme: Student pathway for care workers from the Philippines and other Asian countries’, in Y. Tsujita and O. Komazawa (eds.), Human resources for the health and long-term care of older persons in Asia. Chiba: IDE JETRO and ERIA. Choy, C.C. (2003) Empire of care: Nursing and migration in Filipino American history. USA: Duke University Press. Department of Labor and Employment, Philippines (2019) ‘Guidelines on the deployment of workers to Japan under the status of residence “Specified Skilled Worker”’, Department Order’ No. 201–219. Available at: https://www.dole.gov.ph/news/ department-order-201-19-guidelines-on-the-deployment-of-workers-to-japan-under-thestatus-of-residence-specified-skilled-worker/ (Accessed: 10 February 2022). Flatau, P., Petridis, R. and Wood, D. (1995) Immigrants and invisible underemployment. Canberra: Australian Government Publication Service. Galgoczi, B., Leschke, J. and Watt, A. (2009) ‘Intra-EU labor migration: Policy responses’. In EU labour migration since enlargement: Trends, impact and policies. Surrey: Ashgate.

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Gotehus, A. (2021) ‘Agency in deskilling: Filipino nurses’ experiences in the Norwegian health care sector’, Geoforum 126, pp. 340–349. Guevarra, R. (2010) Marketing dreams, manufacturing heroes: The transnational labour brokering of Filipino workers. New Jersey: Rutgers University Press. Hirano, Y. (2018) ‘Securing Asian care workers in the era of globalization: Care workers entering japan under economic partnership agreements’, Japanese Sociological Review 68 (4). Hochschild, A.R. (2000) ‘Global care chains and emotional surplus value’, in W. Hutton and A. Giddens (eds), On the edge: Living with global capitalism. London: Jonathan Cape. IOM – International Organization for Migration (2013) Crushed hopes: Underemployment and deskilling among skilled migrant women. Geneva. Korzeniewska, L. and Erdal, M.B. (2021) ‘Deskilling unpacked: Comparing Filipino and Polish migrant nurses’ professional experiences in Norway’, Migration Studies 9 (1), pp. 1–20. doi:10.1093/migration/mnz053. Masselink, L. and Lee, S.D. (2010) ‘Nurses, inc.: Expansion and commercialization of nursing education in the Philippines’, Social Science & Medicine 71, pp. 166–172. doi:10.1016/j_socscimed.2009.11.043. MHLW – Ministry of Health, Labour and Welfare, Japan (no date) website. Firipinjin kangoshi kaigo fukushishi kouhosha no ukeire nitsuite. Acceptance of Filipino Nurse/ Nursing Welfare Candidate. Available at: https://www.mhlw.go.jp/stf/seisakunitsuite/ bunya/0000025247.html (Accessed: 31 May 2021). Mizuho UFJ Research and Consulting Co. Ltd. (2019). ‘Guidebook for care service providers on employment of foreign care workers’. Research on Establishment of Acceptance for Foreign Care Workers commissioned by the Japan Ministry of Health, Labor and Welfare. Available at: https://www.mhlw.go.jp/content/12000000/ 000526603.pdf (Accessed: 23 February 2022). Navallo, K. (2020) Paid to care: The ethnography of body, empathy and reciprocity in care work among Filipinos in Japan. Unpublished doctoral dissertation. Kyoto University, Japan. Ogawa, R. (2012) ‘Globalization of care and the context of reception of Southeast Asian care workers in Japan’, Southeast Asian Studies 49 (4), pp. 570–593. Ohno, S. (2012) ‘Southeast Asian nurses and caregiving workers transcending the national boundaries: An overview of Indonesian and Filipino workers abroad’, Southeast Asian Studies 49 (4), pp. 541–569. Ortiga, Y. (2018) ‘Learning to fill the labour niche: Filipino nursing graduates and the risk of the migration trap’, The Russell Sage Foundation Journal of the Social Sciences 4 (1): pp. 172–187. Ortiga, Y. (2014) ‘Professional problems: The burden of producing the “global” Filipino nurse’, Social Science & Medicine115, pp. 64–71. Parreñas, R. (2001) Servants of globalization: Women, migration and domestic work. California: Stanford University Press. Paul, A.J. (2015) ‘Capital and mobility in the stepwise international migrations of Filipino migrant domestic workers’, Migration Studies 3 (3), pp. 438–459. Philippine Nurses Association (2010) Position paper on the plight of Filipino Nurses under JPEPA implementation.23 August. Available at: https://www.pna-ph.org/ component/attachments/download/251 (Accessed: 9 September 2019).

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Philippine Nurses Association (No date) Position paper on Filipino nurses as caregivers/Care Workers in Japan. Available at: https://www.pna-ph.org/component/atta chments/download/280 (Accessed:10 September 2019). Philippine Nursing Act (2002) Available online at: https://www.officialgazette.gov.ph/ 2002/10/21/republic-act-no-9173/ (Accessed: 9 September 2019). POEA Circular (2009) Guidelines for the recruitment and deployment of Filipino nurses (Kangoshi) and Caregivers (Kaigofukushishi) for Japan on a Government-togovernment Agreement. Available at: https://www.poea.gov.ph/memorandumcircula rs/2009/3.pdf, (Accessed: 18 February 2022). Pratt, G. (1997) ‘Stereotypes and ambivalence: The construction of domestic workers in Vancouver, British Columbia’, Gender, Place and Culture 4 (2), pp. 159–177. Pratt, G. (1999) ‘From registered nurse to registered nanny: Discursive geographies of Filipina domestic workers in Vancouver, B.C.’, Economic Geography 75 (3), pp. 215–236. https://doi.org/10.1111/j.1944-8287.1999.tb00077.x. Rodriguez, R. (2010) Migrants for export: How the Philippine state brokers labour to the world. Minneapolis: University of Minnesota Press. Salami, B., Meherali, S. and Covell, C.L. (2018) ‘Downward occupational mobility among baccalaureate-prepared, internationally educated nurses to licensed practical nurses’, International Nursing Review 65 (2), 173–181. doi:10.1111/inr/12400. Salami, B., Nelson, S., Hawthorne, L., Muntaner, C. and McGillis Hall, L. (2014). ‘Motivations of nurses who migrate to Canada as domestic workers’, International Nursing Review 61 (4), pp. 479–486. https://doi.org/10.1111/inr.12125. Williams, F. (2014) ‘Making connections across the transnational political economy of care’, in B. Anderson and I. Shutes (eds), Migration and care labour: Theory, policy and politics. Hampshire: Palgrave Macmillan. Yeates, N. (2009) ‘Production for export: The role of the state in the development and operation of global care chains’, Population, Space and Place15, pp. 175–187. Yeates, N. (2011) ‘Going global: The transnationalization of care’, Development and Change 42 (2), pp. 1109–1130.

6

Dreams Interrupted Migrant Filipino Nurses, Gendered Nationalism and Ontological (In)Security during the COVID-19 Pandemic1 Jean Encinas-Franco

Introduction Philippine President Rodrigo Roa Duterte remarked in his late-night public address that health workers “are lucky to die for their country” (Santos 2020), as COVID started to spread in late March 2020. By then, hospitals and medical associations had decried the shortage of personal protective equipment (PPE), even as an increasing number of healthcare professionals had already died. Days after this statement, Duterte would ban the emigration of health professionals (POEA 2020a), the majority of whom were nurses (Abrigo and Ortiz 2019, p.6). The order was subsequently revised amid protests. Firstly, it allowed those to leave with pre-existing contracts, and an initial cap of 5,000 (POEA 2020a) was imposed, and eventually increased to 6,500 in 2021 for newly hired health workers (POEA 2021). This chapter argues that the ban illustrates a gendered nationalism which was caused by the need to restore the state’s ontological security amid pandemic-induced uncertainties. Populist responses to COVID-19 have generated media and academic interest across the world. Parallel to these developments is the heightened revival of nationalist ventures, or so-called “COVID nationalism”, in which vaccine hoarding and border closures are introduced to protect citizens (Bieber 2020). Meanwhile, feminist scholars have long argued that nationalist projects are gendered, as in these women are called to perform their traditional roles in the nation’s name (Peterson 1994; Agius et al. 2020; Ng 2020). In other words, such initiatives often constitute the “feminine” or women’s bodies as markers of national identity. Furthermore, these scholars posit that in the context of COVID-19, a form of “gendered nationalism” (Agius et al. 2020), or “masculinist nationalism” (Ng 2020), has been emerging. This chapter joins feminists’ claims in interpreting Philippine President Rodrigo Duterte’s COVID-19 era emigration ban on migrant Filipino nurses as a form of populist politics, framed within the logic of gendered nationalism. It draws from Peterson’s (1994) definition of gendered nationalism, indicating how women’s roles, as child-bearers and markers of national belonging and identity, are mobilised in the name of the state’s agenda. According to DOI: 10.4324/9781003218449-7

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this scholar, such is the case even if women’s concerns may not necessarily concord with those of the nation-state (Peterson 1994, p. 82). Thus, this chapter highlights the implications of Rodrigo Duterte’s gendered response to the nursing workforce, the overall healthcare delivery in the Philippines, and the global supply of nurses, given the country’s role as a major source of nurses worldwide. Using case studies, and employing Feminist Critical Discourse Analysis (FCDA) of available policy documents and selected media accounts, the chapter examines Duterte’s emigration ban, a major pandemic response strategy. It interprets such practice as constituting gendered nationalism and that Duterte navigated it from a “masculinist promotion of the nation” (Agius et al. 2020, p. 434). The discussion below is instructive of how populists used their masculinist entitlement in responding to the pandemic-induced ontological insecurity. It is argued that the COVID-19 pandemic has become a “critical juncture” threatening ontological security (Gülseven 2021), thereby compelling populists to employ masculinist and gendered responses to the pandemic (Agius et al. 2020; Ng 2020). Agius et al. (2020: p.433) posit that populists respond to societal uncertainties or “ontological insecurities”, such as COVID-19, and that they “appropriate the national narrative and reshape it, emphasising specifically gendered traits of the nation, that are then pushed to the centre of political debates”. This resonates with Delehanty and Steele’s (2009) argument that the masculine state marginalises a feminised and “internal other” to shore up its ontological security, in such a way that the latter may also provide resisting discourses on the state’s dominant narrative. Notably, the Philippines experienced one of the world’s longest lockdowns (Hapal 2021). As health worker deaths made headlines,2 Duterte praised them for their sacrifice and their heroism (Santos 2020). Yet, as noted above, the pandemic also threatened the collapse of the nation’s already fragile health system. Citing this very reason, Duterte ordered a ban on health worker emigration in April 2020. The country’s migrant nurses, nearly 70 per cent of them women (DRDF 2021), were among the most affected. While discussions on a populist response to the pandemic have been a subject of media and a growing academic literature, little has been said about cases from the Global South or non-European and non-North American contexts. A Global South perspective is important in unravelling how populists adapt to local contexts, even as they also deploy strategies practised in the Global North (Royandoyan and Braga 2020). Therefore, this paper contributes to this conversation in three ways. Firstly, it expands the literature on populism, gender, and migration, from the Global South context, which is increasing though it has received relatively little attention compared to the Global North. Secondly, linking the concepts of ontological security and gender broadens the analytical lens in looking at nurse migration from the oft-cited “brain-drain” and “pushpull’ factor literature. Thirdly, the introduction of ontological security and gender in understanding the COVID-19 response adds to policy and academic conversation by linking the two.

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The chapter is structured in the following manner. The first part foregrounds the discussion with a brief context of Filipino nurse emigration. A brief overview of the literature of populism, gendered nationalism, and ontological security and how they can be combined to frame the chapter, follows. Next, the data collection and the methodological approach of the study are explained. Finally, the last part discusses Duterte’s ban/cap, its gendered implications, and the surrounding discourses.

Background: The Philippines and its mobile nurses The Philippines is one of the world’s largest exporters of nurses (Lorenzo et al. 2007), 70 per cent of whom are women: a huge majority. A product of the United States’ colonial legacy, nursing has become an essential source of remittances to the Philippine economy. Money transfers from abroad provide vital welfare sources for families, and boost the country’s gross domestic product (GDP). Filipino nurses are currently in great demand in the United States, United Kingdom, and the Middle East. Since 1974, contemporary out-migration has been state-sponsored, as migrant remittances are key contributors to the country’s economy. In 2019 alone, the country received USD 30.1 billion of remittances from Filipinos abroad (Bangko Sentral ng Pilipinas 2021). Ageing demographics in affluent countries, where nursing is no longer considered a viable occupation by the locals, has heightened the demand for foreign nurses. For this reason, the World Health Organization (WHO) projects that 4.6 million nurses will be needed by 2030 (WHO 2020). In the Philippines, the poor working conditions and low salaries in the healthcare system drive nurses to look for overseas jobs. Immigration arrangements facilitating family unification and better career prospects also attract Filipino nurses to work abroad. Recent estimates indicate an annual average of 15,000 to 20,000 Filipino nurses going abroad, with about 240,000 Philippine-born nurses working in the OECD (Buchan and Catton 2020, p. 11). Current estimates indicate that Filipino nurses still comprise a third of immigrant nurses in the US (Thornell 2020). Nursing schools also responded to the demand for nurses such that from only 17 in 1950, they exponentially increased to 370 by 2005 (Trines 2018), an offshoot of the state’s vigorous promotion of a nursing degree. Over the years, despite public and academic discourse on the “brain drain”, many Filipino nurses have been employed abroad. Thus, over the course of 20 years, it is estimated that some 250,000 Filipino nurses were practising in 31 countries (Trines 2018), which is almost half (580,000) of the nurse professionals produced by the country in the same period (FNU 2021). At one point, the country witnessed an increase in doctors training to become nurses (Lorenzo et al. 2007, p. 1410). Nurse migration was perceived as such an attractive and lucrative career option, that some Filipino doctors opted to retrain as nurses, in order to find jobs overseas. The American colonial government influenced the development of the Philippine nursing curriculum, to prepare the country’s health system post-

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independence. Under the Pensionado Law of 1903, Filipinos were sent abroad to train as nurses to learn advanced skills, and to provide quality healthcare after their return. Post-independence, the Exchange Visitor Program also enabled nurses to train and study in the US. However, subsequent emigration waves were made in response to US health worker shortages following the 1965 Immigration and Nationality Act. Meanwhile, Filipino nurses’ contemporary migration pattern is facilitated by the state-sponsored overseas employment programme established by the then President Ferdinand Marcos in 1974 (Masselink and Lee 2013, p.91). What was then a stop-gap measure, to respond to the unemployment brought about by the oil-price crises of the 1970s, became an economic strategy. The government’s bureaucratic apparatus was swiftly formulated, catering to migrants’ needs from pre-employment to repatriation and reintegration, thereby making it, as has been widely quoted in international discourse, a “best practice” in migration governance (Oh 2016). Current migration governance, however, struggles to balance the benefits of outmigration and its negative implications, including the insufficient protection of Filipino migrant workers’ human and labour rights. Such tension is heightened in life-and-death cases of migrants receiving wide media and public attention.3 With reference to women migrants, scholars often frame the migration governance regime as “paternalist” (Pande 2014; Parrenas 2008). The latter implies that, not only are migrant women subjected to strict state surveillance, in terms of their training and pre-departure orientations, but their mobility is also largely determined by the state. For this reason, deployment bans are common, specifically among domestic workers, particularly when cases of exploitation, abuses, and deaths abroad, generate wide public attention. On the part of nurse emigration, these tensions and contradictions have compelled the Philippines to embark on bilateral labour agreements (BLA) with other host countries such as Japan, the United Kingdom, and Germany, among others. Furthermore, the nurse recruitment agencies, operating in the Philippines, are required (or encouraged) to follow ethical norms in their recruitment practices (Encinas-Franco 2016). However, reports of racism, human trafficking, and unfair labour practices, are all challenges, which have still to be addressed. Though the pandemic has seemingly brought increased visibility to health workers, migrant Filipino nurses still experience triple structural invisibility. It is argued that this undervaluation is reinforced by the perception of nursing as being about women’s “natural” and “caring” skills (Bourgeault et al. 2021, p. 2). Such undervaluation extends to their invisibility in host and origin states, and often leads to unsound, and non-evidencebased, policies. These invisibilities occur in three instances at different stages of their migration journey: when they are outside the medical field, when they are deskilled, and when they are “lumped” together with other ethnicities in host countries. The first instance of structural invisibility is linked with the phenomenon of a “migration trap” (Ortiga 2018). In the Philippines, vigorous

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state promotion of nursing degrees, as pathways to lucrative overseas jobs, has been described as having produced a “migration trap” (Ortiga 2018). Over the last ten years, the global demand for migrant health workers has fallen noticeably. As a result, many Filipino nurses, who initially planned to find jobs overseas, were not able to do so. Furthermore, they were unable to find jobs in their home country either, partly due to no jobs being available offering an appropriate and desired level of salary. An entry level salary for government nurses ranges from USD250 to USD400 depending on the financial capacity of the local government unit (USAID HRH2030/Philippines 2020). Wage differentials are even higher when compared to salaries in host states in Europe and North America. Estimates indicate that the salary of an emigrant nurse is about five times as high as that of a local nurse (Dancel 2021). The common perception is that there is a shortage of nurses in the Philippines. However, data from the Philippine Regulatory Commission (PRC)4 indicate a surplus of nurses in the country, even if licensure applicants have been decreasing in recent years (Cortez 2020). They are, however, generally unaccounted for mainly because they end up in non-medical fields. The second dimension of the structural invisibility experienced by Filipino nurses is deskilling. As reported in previous studies, many Filipino nurses aim to pursue overseas careers. However due to various immigration challenges, including the recognition of their nursing qualifications abroad, some nurses turn to caregiving and other work, and end up becoming deskilled. In Canada for example, a substantive percentage of Filipino nurse graduates are overqualified for their jobs (Cornelissen 2021). When they leave, government data reports them as caregivers and not nurses, since the POEA accounts for the work stated in their contracts and not their professions. The third case of nurse invisibility occurs due to the gaps in the data collection methods employed in some host countries, where the differences within migrant ethnic groups are often obscured. For instance, the pandemic has brought to light how the UK’s data systems have “invisibilised” migrant healthcare professionals, including Filipino nurses. In the NHS, COVID-19 deaths of foreign-born nurses have exposed their invisibility in the BAME (Black, Asian, and Minority Ethnicity) classification. The BAME is the NHS system’s mode of health worker classification, in which non-White employees are classified under BAME, despite ethnicity differences. Such invisibility became crucial when understanding the social and physiological determinants of COVID-19 severe cases and deaths (PHE 2020). Thus, there are calls to dis-aggregate data per ethnicity, to better understand and serve migrant workers’ health needs (Adia et al. 2020).

Ontological security, COVID-19, gendered nationalism and the state The pandemic challenged peoples’ lives and routines, generated uncertainties, and disrupted ontological security. Ontological security refers to the individual’s sense of safety which then provides him or her with continuity enabling

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a sense of stability in the surrounding environment (Giddens 1990, p. 92), which was disrupted when COVID-19 struck. The term has been used extensively in the field of International Relations in relation to states, but scholars attribute its roots to psychologist R.D. Laing, and even beyond (Gustafsson and Krickel-Choi 2020, p. 876). An important theme of this chapter is that, during these moments, the state loses its “sense of being”, or “national purpose”, compelling it to “articulate the justificatory reasons for engaging in moral action” (Delehanty and Steele 2009, p. 532). To bring back their selfidentity, states usually turn to “autobiographical narratives” or “a narrative that uses historical experiences of that Self to provide comforting stories [about the Self]” when ontological security is threatened (Delehanty and Steele 2009, p. 524). However, the sense of ontological security may not be monolithic within the state. Thus, this does not discount the possibility that counter-narratives may exist, usually coming from a feminised “internal other” (Delehanty and Steele 2009, p. 524). In this discussion nurses and their profession are perceived as the feminised internal “other”, falling prey to Duterte’s masculinist ban on their emigration. In their bid for ontological security, states turned inwards, or to nationalism, to respond to medical shortages, the supply of vaccines, and border controls, thereby heightening pre-pandemic racism and xenophobia (Elias et al. 2020). For example, the United Kingdom has resorted to myths and narratives, such as the “Blitz Spirit”, and the valorisation of the National Health Service and its workers (Kirke 2020). One reason offered for these developments is that “the attentiveness to life and its value that has resurfaced in the COVID-19 moment all too predictably stops at the borders of race and nation” (James and Valluvan 2020, p. 1246). World leaders’ speeches on the pandemic, for example, reproduce the “dichotomy of national versus international interests”, which often includes control of border and invocations of “patriotic duty and sacrifice” (Dada et al. 2021, p.6). In linking ontological security and populist studies, Steele and Homolar (2019, pp. 215–216) summed up the three concepts shaping the analytical focus: routines and anxiety; narratives and memory; and crisis and insecurity. Accordingly, when confronted with uncertainties, agents (of the state) normally maintain routines to manage the peoples’ anxieties. However, expertise is sometimes compromised in the face of disruptions, thereby providing populists with space to deny facts or scientific explanations. Narratives and memory aid populists in invoking the past to generate inter-group solidarity necessary during anxious moments. Finally, populists utilise crises to instil a sense of insecurity that they can use to manipulate their polity and legitimise their actions. Meanwhile, a key component framing these responses is an appeal to a gendered logic of nationhood by populists, such as Trump and Bolsonaro (Agius et al. 2020; Ng 2020). Nonetheless, empirical evidence of a gendered nationalism from the Global South is absent in these discussions. While there are emerging narratives labelling Duterte as a populist invoking sexist and

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misogynistic tropes (De Chavez and Pacheco 2020; Gregorio 2020; Gutierrez 2017; Parmanand 2020), so far, none have accounted for a gendered nationalism in the context of migration. The discussion above suggests that understanding populist responses to ontological insecurity amid the pandemic is specifically important in the context of migration and gendered nationalism. More importantly, there is considerable space in looking at it from the Global South’s perspective.

Methods and data collection The chapter uses interpretive case study as an approach to present Duterte’s deployment of a migration ban/cap on Filipino nurses, and to explore its consequences and gendered implications. In discussing the ban/cap, this chapter has utilised different data sources such as policy documents, reports related to COVID-19 response and nurses, and relevant news reports. (See Appendix for a complete list.) The time frame for the selection of these media statements was April 2020 to October 2021. Consistent with the feminist and interpretive lens used in this study, the policy and media texts were interpreted based on Feminist Critical Discourse Analysis (FCDA) (Lazar 2007), in which the researcher looked for texts for words and phrases invoking feminised and masculinised roles, and how these are projected to be nurses’ taken-for-granted duties in the name of the nation. For example, feminine roles are ascribed to women, due to their biology and “natural” predispositions as carers and nurturers. Masculinised roles are normally ascribed to men as “protectors” or those that imply hierarchy over women. Although the ban initially covered different categories of health workers, the chapter focuses only on migrant nurses, because they comprise the majority of health workers, and are the most affected by the ban.

Discussion Duterte’s COVID-19 response and Filipino migrant nurses’ immobility Duterte organised one of the most militarised responses to the spread of the virus (Hapal 2021). Two policies foregrounded Duterte’s masculine and militarised pandemic response: the declaration of the state of public health emergency or Proclamation 922, and the Bayanihan to Heal as One law (Senate of the Philippines 2020), granting him emergency powers, among others. As soon as local transmission was reported in early March 2020, Duterte declared a state of public health emergency, similar to what other countries did. In Proclamation 922, he stated that COVID-19 “threatens national security” and requires “a whole of government response…[citizens and even tourists are directed to] act within the bounds of the law and comply with the lawful directives” (Official Gazette 2020a). A few weeks after, Congress granted emergency powers to Duterte and approved the Bayanihan Law,

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allowing him, among others, to direct the health department to hire temporary health workers to respond to the crisis, and to provide “hazard pay” for those attending to COVID patients. This law was further succeeded by the Bayanihan to Recover as One Law approved towards the end of 2020 (Official Gazette 2020b). With the danger of the pandemic spreading, and the potential collapse of the health system, these policy pronouncements arguably framed the government’s bid to quell the pandemic. Key components in fighting the pandemic are health workers, specifically nurses, of which the country’s health system is in short supply. Of the 488,800 health professionals in the country, 75 per cent are women, while 59 per cent are nurses (DRDF 2021, pp. 2–3). Along with midwives, nurses receive the lowest salary. As of 2018, nurses received an average monthly wage of less than USD 300, which is below the Philippine poverty threshold for a family of five (DRDF 2021, p. 5). In April 2020, Duterte ordered a “temporary” ban on healthcare workers. under the so-called Mission-Critical Skills (MCS). The latter refers to “those skills that reflect the primary function of the organization without which mission critical work cannot be completed and which skills are internally developed and require extensive training, thus, not easily replaceable” (POEA 2020a, p.1). Under the order, health professionals are banned from emigrating abroad until the state of emergency ends, and the restrictions in host countries are lifted. MCS was established to stop a brain-drain, and pacify Philippine industries and sectors occasionally facing worker shortages. To respond to social media protests, the government had to adjust the ban twice in 2020 by allowing some nurses, whose contracts had already been processed, to leave. In December 2020, the ban was “lifted”, and instead a 5,000 annual cap was imposed on migrant nurses (POEA 2020a). Then the cap was increased to 6,500 Filipino nurses who were allowed to leave yearly (POEA 2020b). As of the end of October 2021, the cap had already been filled, which meant that nurses without a processed overseas employment certificate (OEC) were unable to leave. Because of the ban/cap, the migrant recruitment industry projected that an estimated 500,000 health professionals could not leave for abroad (Depasupil 2021). From the perspective of ontological security (Delehanty and Steele 2009), the Duterte administration invoked its autobiographical narrative in imposing the ban/cap. As discussed earlier, memory, narratives, and routines, are important elements in a state’s repertoire in promoting its autobiography in ontologically insecure moments. Though the ban/cap on health workers is new, the deployment ban, particularly for domestic workers, has been a regular feature of the government’s management of overseas employment, particularly in cases of highly publicised abuse (Shivakoti et al. 2021). Bans are also imposed on conflict-affected areas, coupled with repatriation efforts to allow migrants to return to their families in the Philippines. This is a key feature of the country’s national security, which identifies overseas Filipinos as one of the three pillars of the country’s national interest.5 Therefore, Filipinos and host states are all too familiar with this state behaviour relative to migrants.

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In relating with its emigrants, the Philippine state has often positioned itself as a “protector” (Encinas-Franco 2013) so as to downplay the government’s reliance on labour export. As has been discussed above, this is particularly heightened in the life-and-death situations of Filipino migrants. Feminist scholars, however, argue that this role is also paternalistic (Pande 2014; Parrenas 2008), as the “protector” role is often seen in the deployment ban, and the stricter regulations against women migrants, particularly those in the care sector, such as domestic work. The ban/cap on nurses reflects this trend even if, ostensibly, its overall intention is to ensure a sufficient supply of health professionals for the COVID-19 response. Duterte articulated this narrative days after ordering the ban. Cognisant then of the initial negative response by health professionals to the ban, he used the “protector” stance in justifying his government’s action. In one of his regular nightly COVID press briefings, he remarked, If I send you to the warfront, I will feel bad exposing you to the enemy, which is COVID. Please do not misunderstand me. I am making it clear now. I do not want you to go there and come back in a coffin. (CNN 2020) He justified this as a “valid reason” to stop doctors, nurses, and other healthcare workers from leaving the country (CNN 2020). When the state and its officials position themselves as protectors, they also position nurses as the “protected”, justifying the ban imposed on them. It also hierarchically puts the state in a superior and masculinist position,even as it portrays nurses as the “inferior” and feminised “internal other” (Delehanty and Steele 2009). Such a scenario legitimises mobility restriction, and makes it palatable to the general public. However, it robs nurses of their agency, perceives them as potential victims, and infantilises their decision-making abilities to emigrate. A key phrase mentioned in the policy and media texts is “national interest”. In the initial deployment ban, the rationale was stated as “of paramount national interest to ensure that the country shall continue to have, sustain the supply, and prepare sufficient health personnel to meet any further contingencies” (POEA 2020a, p.2). In appealing to health workers’ sense of patriotism and nationalism, the presidential spokesperson invoked that they needed to stay in the country because no one else would care for their families, implicitly suggesting that their migration goals needed to be rethought due to the pandemic (Aurelio 2020). Clearly, the appeal to migrants’ sense of nationhood is nothing new. The nation has always been implicated in the relationship between the state and migrant Filipinos. In the 1970s, state-sponsored contemporary out-migration was due to President Ferdinand Marcos’ regime’s balance of crisis payments problem – to address employment problems and generate much-needed dollars for the economy. Marcos signed the 1974 Labour Code and required mandatory sending of remittances, a move that was repealed years later

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(Tigno 2000, p.59). In the 1970s, balikbayan (translated literally as “return to the nation”) had been the label used for permanent Filipino migrants visiting the Philippines, and spending their dollars for tourism purposes (Blanc 1996). In the late 1980s and 1990s, the term “modern-day heroes” was coined to refer to labour migrants’ contribution to a remittance-dependent economy (Encinas-Franco 2013). It is ubiquitous in state discourses valorising their sacrifices. For this reason, the quote above is a familiar trope: nurses’ sacrifice for their families extends to the nation. Dreams interrupted: The ban’s gendered implications on Filipino migrant nurses F. Flordeliza, who was about to move to the UK in 2020, captured the plight of migrant nurses as a result of the ban: The temporary ban on health care workers ensued like a mugger trying to steal my best laid plans. It was the same day I became a PrisoNurse, trapped in the country where we are not properly compensated nor appreciated. The so-called suspension of deployment triggered an outcry for many of us whose papers were already in the pipelines. (Flordeliza 2020) As follows from this quote the ban disrupted nurses’ long-term plans, and starkly reminded them of their dismal situation in the Philippines. The ban/cap’s implications are inherently gendered for two inter-related reasons. Firstly, it disproportionately affected women as they form a majority of health workers. Secondly, by linking nationalism and care, the government (and society) feminises nurses’ jobs and emphasises their role for the nation and their families. Therefore, these two reasons frame the state’s justification for the ban, by making it seem that their “sacrifice” is not so much for the nation as it is for their families. But a key contradiction belies this formulation. Some Filipino nurses, health workers, and labour migrants choose to go abroad because of their families’ financial needs. Recouping investments made on their education and training for jobs abroad is another reason. For this reason, the government COVID emergency hire programme was not sustainable for those who had already invested time and money for moving abroad, amounting to as much as USD2,000 (House of Representatives 2020, p.2). Besides, while providing allowances and other benefits, the programme only hires nurses for three months to cope with the pandemic surge. Moreover, the dismal working condition such as the “lack of accommodation and transport support, lack of standard protocol and guidelines” (House of Representatives 2020, p.2) were discouraging. The Bloomberg Covid Resiliency Index in October 2021 also placed the Philippines at the bottom of 53 countries in terms of COVID response (Calonzo 2021). The different waves of COVID surges since 2020 put a severe strain on the country’s hospitals and overall health system, prompting many health

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workers, including nurses, to leave the health system (Salaverria 2021). This has been exacerbated by delayed allowances amid reports of corruption in the health department (Salaverria 2021). The travel ban/cap may have also exacerbated the “migration trap” (Ortiga 2018), as nurses looked for jobs elsewhere while they awaited the ban’s lifting. The above discussion suggests that the “protector–protected” narrative has its inherent contradictions and can be challenged. Even if both the Philippines and host countries grappled with the, then novel, COVID-19 virus in early 2020, the latter have far better health facilities to address the pandemic. At the very least, it is perceived that their jobs and financial security in the host countries outweigh the risk of COVID.6 Decades of health underspending have resulted in a weak health infrastructure, which is unable to provide decent jobs for its health workers. Philippine health expenditure has not reached the World Health Organization standard of at least five per cent of government spending (Castro-Palaganas et al. 2017, p. 2). Indeed, emboldened by their increased media and policy visibility brought by the pandemic, nurses resisted the ban. A group of directly affected nurses called themselves “PrisoNurses” and launched social media campaigns to end the ban. In a press statement, the Filipino Nurses United (FNU), a labour association of public and private sector nurses, including those working overseas, rejected the government’s nationalist discourse by denouncing the nurses’ poor working conditions in the country and which according to them is already proof of their daily sacrifice for the nation, long before the pandemic (FNU 2021). Furthermore, the minister of Foreign Affairs argued that the ban was a violation of the constitutional right to travel and the inviolability of contracts (Aning 2020). Nurse supply, “migration trap”, and migration diplomacy More than ever, the ban/cap on nurses manifests the tension between domestic health needs and the imperative to send them abroad for remittances and employment. Unsurprisingly, a key discourse surrounding the ban is local nursing supply. Existing data show that there are 996,245 health workers, and more than 74 per cent of them are nurses (USAID HRH 2030/Philippines 2020). In the policy documents, however, a marked shortage was highlighted. The ban’s directive stated that, based on a government evaluation of health professionals benchmarked with global standards, “there was a shortage of about 290,000 health workers in the country, and that an average annual migration of 13,000 healthcare professionals aggravates the deficiency in the national supply” (POEA 2020a, pp.1–2). Missing in this account is the “migration trap” discussed earlier, in which nurses flock to non-medical sectors such as business process-outsourcing (BPO), while waiting for more lucrative overseas opportunities (Ortiga 2018, p.185). By not mentioning this in the directive, the state absolves itself from its debacles that in the first place created the said trap. Steel and Homolar

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(2019, p. 216) contend that states sometimes have to resort to a denial of facts to construct a crisis. Moreover, such silence and omission are also gendered, mainly because it makes nurses, many of them women, invisible, when in fact their career choices were largely influenced by the state’s promotion of nurse migration to attract remittances. At the same time, by not mentioning the real situation, the state treats it as unproblematic, thereby furthering nurses’ already dismal condition as “PrisoNurses”. What this government narrative suggests is that the migration trap is not a concern that the state thinks should be urgently addressed. Silence is important in feminist analysis, as while uttered texts are explicitly articulated, what is not said also often yields vital analytical points (Huckin 2002, p. 366). Meanwhile, continued travel restrictions and a cap may affect supply in countries that have been reliant on foreign nurses. The cap of 6,500 for new hires stands to decrease the supply of newly hired nurses in countries increasingly facing an ageing demographic, and an ageing nursing workforce. Buchan and Catton (2020, p. 17) present many scenarios from host and destination countries to cope with post-pandemic nurse supply. However, in the mid-term, depending on the evolution of the pandemic, the ban/cap stands to affect nurse supply in host countries, even as they are already grappling with shortages pre-pandemic. Two destination states with existing bilateral agreements with the Philippines, namely Germany and the UK, immediately wanted the ban/cap to be lifted. Meanwhile, government statements indicate that they held talks with governments of the UK and Germany on plans to exempt them from the 5,000 quota in exchange for a vaccine supply (Depasupil 2021). When the vaccine rollout began in the developed world, the media reported that the country’s labour secretary called on the British ambassador for the government to allow Filipino nurses to leave in exchange for vaccines from the UK (Morales 2021). Reuters even cites the director of the Philippine labour ministry’s international affairs bureau as being open to lifting the cap so that the UK and Germany could send vaccines in exchange, which would be used by workers bound for abroad and those who had been repatriated (Morales 2021). Though this was later denied, its reporting already indicates how nurses’ labour has become commodified in the interest of diplomatic bargaining. When severely criticised by the political opposition, the FNU and the Philippine Nurses Association (PNA), the government denied this news account. A former politician compared the proposed deal to “human trafficking” (Mendiola 2021). The FNU decried the vaccine-for-nurses plan and accused the government of treating them as disposable properties (Morales 2021). Both the UK and Germany have since been exempted from the ban/ cap. Moreover, a more detailed Memorandum of Understanding on health worker professionals between the UK and the Philippines was also signed in October 2021 (Gov.UK 2021). This agreement guarantees ethical recruitment, improved training of nurses, and enhanced cooperation in fighting COVID-19.7

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Conclusion This chapter has endeavoured to show that Rodrigo Duterte utilised gendered nationalism in banning/issuing a cap on nurse migration during the COVID-19 crisis. In responding to the pandemic-induced ontological insecurity, the Philippine state used its masculinist autobiographical narrative in ways that reiterated past routines, evoking the narratives of “protector–protected”, and thereby legitimising the move. However, the ban exposed the government’s dismal treatment of Filipino nurses in both the pre-pandemic and pandemic periods. Moreover, nurses were not only displaced by the ban/cap, but also “invisibilised”, or silenced and commodified by such policies. Nurses and their allies, nonetheless, have been resisting the ban/cap in strategic ways. They have also used the pandemic and the ban/cap to urge the government to find ways to retain nurses in the country in the longer term, even as they recognise the injustice of it all. The analysis extends previous work on ontological security and gender, specifically that pertaining to COVID-19 such as Agius et al. (2020). More specifically, the chapter provides a nuanced view of nurse migration and gendered nationalism from developing states. Because the case deals with the context of nurses’ international migration and state-control of their mobility, the chapter widens the explanatory reach of nurse migration studies that normally focus on push-pull factors and occupational hazards. By looking at it through the lens of a populist gendered response to ontological security, the chapter has sought to present a more political understanding of nurse migration from the perspective of the sending state. Future research may focus on the modes and discourses of resistance that nurse migrants have waged to contest the masculinist state narrative. Other cases of migrant-sending states from the Global South may also be examined so that comparative cases and responses can be discussed.

Notes 1 This work was made possible with the Research Load Credit granted by the University of the Philippines in the Academic Year 2020-2021. . 2 As of November 25, 2020, 12,000 healthcare workers had COVID-19, 76 of them died. See World Health Organization (2020). Philippines Coronavirus Disease 2019 (COVID-19) Situation Report #63. Available at https://www.who.int/docs/defaultsource/wpro—documents/countries/philippines/emergencies/covid-19/who-phl-sitrep63-covid-19-25november2020.pdf?sfvrsn=670c4703_2&download=true 3 In 1995, Singapore executed Flor Contemplacion, a Filipino domestic worker who was found guilty of murdering her ward and a fellow Filipino maid. Massive protests nationwide prompted the resignation of the labour and foreign affairs ministers, along with the rush to approve a Magna Carta for Migrant Workers and Overseas Filipinos Overseas Law. 4 The practice of nursing in the Philippines is governed by the Nursing Act of 2002. Students are enrolled in a four-year curriculum, after which they are required to take the nursing board examination. The Philippine Regulation Commission regulates the practice of nursing and other professionals in the country requiring a board examination except the legal profession. 5 The other two pillars are national security and economic security.

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6 However, migrant healthcare professionals working in the COVID-19 frontline also face risks of infection, stress, occupational burnout and discrimination, creating a whole new set of challenges. 7 The UK and the Philippines have earlier agreed on healthcare cooperation in 2002 and 2003 (POEA n.d.).

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at: https://www.asianjournal.com/philippines/across-the-islands/backlash-ensues-afterph-offers-nurses-in-exchange-for-covid-vaccines-from-uk-germany/ (Accessed: 10 November 2021). Morales, N. (2021) ‘Philippines Offers Nurses in Exchange for Vaccines from Britain, Germany’, Reuters, 23 February. Available at: https://www.reuters.com/a rticle/uk-health-coronavirus-philippines-labour-idUKKBN2AN0WV (Accessed: 16 December 2021). Ng, E. (2020) ‘Unmasking Masculinity: Considering Gender, Science, and Nation in Responses to COVID-19’, Feminist Studies, 46 (3), pp. 694–703. doi:10.15767/ feministstudies.46.3.0694. Official Gazette (2020a) Proclamation 922. Declaring a State of Public Health Emergency Throughout the Philippines. Available at: https://www.officialgazette. gov.ph/downloads/2020/02feb/20200308-PROC-922-RRD-1.pdf (Accessed: 6 December 2021). Official Gazette (2020b) Republic Act 11494. An act providing for COVID-19 response and recovery interventions and providing mechanisms to accelerate the recovery and bolster the resiliency of the Philippine economy, providing funds therefore, and for other purposes. Available at: https://www.officialgazette.gov.ph/downloads/2020/ 09sep/20200911-RA-11494-RRD.pdf (Accessed: 16 December 2021). Oh, Y.A. (2016) ‘Oligarchic Rule and Best Practice Migration Management: The Political Economy Origins of Labour Migration Regime of the Philippines’, Contemporary Politics, 22 (2), pp. 197–214. doi:10.1080/13569775.2016.1153286. Ortiga, Y.Y. (2018) ‘Learning to Fill the Labor Niche: Filipino Nursing Graduates and the Risk of the Migration Trap’, The Russell Sage Foundation Journal of the Social Sciences, 4 (1), pp. 172–187. Available at: https://ink.library.smu.edu.sg/cgi/view content.cgi?article=3936&context=soss_research (Accessed: 16 December 2021). Pande, A. (2014) ‘“I prefer to go back the day before tomorrow, but I cannot”: Paternalistic Migration Policies and the “Global Exile”’, Critical Social Policy, 34 (3), pp. 374–393. doi:10.1177/0261018314526008. Parmanand, S. (2020) ‘Duterte as the Macho Messiah: Chauvinist Populism and the Feminisation of Human Rights in the Philippines’, Review of Women’s Studies, 29 (2), pp. 1–30. Available at: https://www.researchgate.net/profile/Sharmila-Parmanand/ publication/344930711_Duterte_as_the_macho_messiah_Chauvinist_populism_and_ the_feminisation_of_human_rights_in_the_Philippines/links/5f997ecfa6fdccfd7b84fddd/ Duterte-as-the-macho-messiah-Chauvinist-populism-and-the-feminisation-of-humanrights-in-the-Philippines.pdf (Accessed: 16 December 2021). Parrenas, R.S. (2008) The Force of Domesticity: Filipina Migrants and Globalization. New York: New York University Press. Peterson, V. (1994) ‘Gendered Nationalism’, Peace Review, 6 (1), pp. 77–83. doi:10.1080/10402659408425777. PHE – Public Health England (2020) Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups. Public Health England. Available at: https://assets. publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/ 892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf (Accessed: 25 August 2021). POEA – Philippine Overseas Employment Administration (2020a) Governing Board Resolution No. 09. Available at: https://www.dmw.gov.ph/archives/gbr/2020/GBR-09-2020.pdf (Accessed: 15 August 2022).

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POEA – Philippine Overseas Employment Administration (2020b) Governing Board Resolution No. 17. Available at: https://www.dmw.gov.ph/archives/gbr/2020/GBR-172020.pdf (Accessed: 15 August 2022). POEA – Philippine Overseas Employment Administration (2021) ‘Increase in the Deployment Ceiling of Newly-Hired MCS Healthcare Workers (HCW)’. Available at: https://www.dmw.gov.ph/archives/advisories/2021/Advisory-79-2021.pdf (Accessed: 15 August 2022). Royandoyan, R. and Braga, M. (2020) ‘Right-Wing Populism Outside the Global North: Brazil and the Philippines’. Available at: https://www.politicalresearch.org/ 2020/07/09/right-wing-populism-outside-global-north (Accessed: 16 August 2021). Salaverria, L. (2021) ‘Exodus of Nurses Alarms Private Hospitals’, INQUIRET.net, 20 October. Available at: https://newsinfo.inquirer.net/1504086/exodus-of-nurses-alarmsprivate-hospitals (Accessed: 16 December 2021). Santos, A. (2020) ‘Attacked & Underpaid: Medics in Philippines Battle Stigma, Virus’, Al Jazeera, 2 April. Available at: https://www.aljazeera.com/news/2020/4/2/attackedunderpaid-medics-in-philippines-battle-stigma-virus (Accessed: 16 December 2021). Senate of the Philippines (2020) Republic Act 11469. An Act Declaring the Existence of a National Emergency Rising from the Coronavirus Disease 2019 (COVID-19) Situation and a National Policy in Connection Therewith, and Authorizing the President of the Republic of the Philippines for a Limited Period and Subject to Restrictions, to Exercise Powers Necessary and Proper to Carry Out the Declared National Policy and For Other Purposes. Available at: http://legacy.senate.gov.ph/Ba yanihan-to-Heal-as-One-Act-RA-11469.pdf (Accessed: 16 December 2021). Shivakoti, R., Henderson, S. and Withers, M. (2021) ‘The Migration Ban Policy Cycle: A Comparative Analysis of Restrictions on the Emigration of Women Domestic Workers’, Comparative Migration Studies, 9 (36), pp. 1–18. doi:10.1186/ s40878-021-00250-4. Steele, B. and Homolar, A. (2019) ‘Ontological Insecurities and the Politics of Contemporary Populism’, Cambridge Review of International Affairs, 32 (3), pp. 214– 221. doi:10.1080/09557571.2019.1596612. Thornell, C. (2020) ‘Why the US Has so Many Filipino Nurses’, Vox, 30 June. Available at: https://www.vox.com/2020/6/30/21307199/filipino-nurses-us (Accessed: 16 August 2021). Tigno, J. (2000) ‘The Philippine Overseas Employment Program: Public Policy Management from Marcos to Ramos’, Public Policy, 4 (2), pp. 37–86. Available at: https:// cids.up.edu.ph/wp-content/uploads/The-Philippine-Overseas-Employment-Programvol.4-no.2-July-Dec-2000-3.pdf (Accessed: 16 December 2021). Trines, S. (2018) ‘Mobile Nurses: Trends in International Labor Migration in the Nursing Field’, World Education News + Reviews, 6 March. Available at: https:// wenr.wes.org/2018/03/mobile-nurses-trends-in-international-labor-migration-in-thenursing-field (Accessed: 16 December 2021). USAID HRH2030/Philippines: Human Resources for Health in 2030 in the Philippines. (2020) Health Labor Market Analysis of the Philippines. Final Report. Available at: https://hrh2030program.org/wp-content/uploads/2020/08/1.1_HRH2030PH_HLMAReport.pdf (Accessed: 25 August 2021). WHO – World Health Organization (2020) ‘Urgent Need for Investment in Nursing: COVID-19 Pandemic Puts Need for Nurses into Sharp Relief ’. Available at: https:// www.who.int/westernpacific/news/item/07-04-2020-urgent-need-for-investment-innursing (Accessed: 16 December 2021).

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Appendix Policy documents Government of the United Kingdom (2021) Memorandum of Understanding on the Recruitment of Filipino Healthcare Professionals between the Government of the Republic of the Philippines and the Government of the United Kingdom of Great Britain and Northern Ireland. https://www.gov.uk/government/publications/memora ndum-of-understanding-between-the-uk-and-the-philippines-on-healthcare-cooperation (Accessed: 5 November 2021). House of Representatives (2020) House Resolution No. 875. Resolution Urging the House of Representatives through the Defeat COVID-19 Ad Hoc Committee on Overseas Workers Affairs to Conduct an Inquiry, in Aid of Legislation, on the Plight of Health Workers Affected by the Deployment Ban in Relation to the COVID-19 Pandemic. https://hrep-website.s3.apsoutheast-1.amazonaws.com/legisdocs/basic_ 18/HR00875.pdf (Accessed: 25 August 2021). Official Gazette (2020a) Proclamation 922. Declaring a State of Public Health Emergency Throughout the Philippines. Official Gazette (2020b) Republic Act 11494. An Act Providing for COVID-19 Response and Recovery Interventions and Providing Mechanisms to Accelerate the Recovery and Bolster the Resiliency of the Philippine Economy, Providing Funds Therefore, and for Other Purposes. https://www.officialgazette.gov.ph/downloads/ 2020/09sep/20200911-RA-11494-RRD.pdf Philippine Overseas Employment Administration (2020a) Governing Board Resolution No. 09. https://www.poea.gov.ph/gbr/2020/GBR-09-2020.pdf. Philippine Overseas Employment Administration (2020b) Governing Board Resolution No. 17. https://www.poea.gov.ph/gbr/2020/GBR-17-2020.pdf. Philippine Overseas Employment Administration (2021) Increase in the Deployment Ceiling of Newly-Hired MCS Healthcare Workers (HCW). https://www.dmw.gov. ph/archives/advisories/2021/Advisory-79-2021.pdf. Senate of the Philippines http://legacy.senate.gov.ph/Bayanihan-to-Heal-as-One-Act-RA11469.pdf

News articles Aning, J. (2020) ‘DFA Chief Hits Deployment Ban on PH Health Workers’, INQUIRER.net, 1 April. Available at: https://globalnation.inquirer.net/186772/dfa-chiefhits-deployment-ban-on-ph-health-workers (Accessed: 15 December 2021). Aurelio, J. (2020) ‘Palace: Ban on Deployment of Health Workers Stays’, INQUIRER. net, 21 August. Available at: https://newsinfo.inquirer.net/1325061/palace-ban-on-dep loyment-of-health-workers-stays (Accessed: 15 December 2021). Calonzo, A. (2021) ‘Philippines is Still the Worst Place to be in Covid even as Cases Ease’, Bloomberg, 27 October. Available at: https://www.bloomberg.com/news/arti cles/2021-10-27/philippines-still-worst-place-in-covid-even-as-cases-ease-off (Accessed: 15 December 2021). Dancel, R. (2021) ‘Filipino Immigrant Nurses Pay Heavy Price as Covid-19 Pandemic Races across the Globe’, The Straits Times, 18 May. Available at: https://www.stra itstimes.com/asia/se-asia/philippines-immigrant-nurses-pay-heavy-price-.as-covid-19pandemic-races-across-the (Accessed: 16 December 2021).

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Depasupil, W. (2021) ‘PH Running Out of Nurses – Bello’, The Manila Times, 28 May. Available at: https://www.manilatimes.net/2021/05/28/news/ph-running-out-ofnurses-bello/1800955 (Accessed: 16 December 2021). Mendiola, R. (2021) ‘Backlash Ensues After PH Offers Nurses in Exchange for COVID Vaccines from UK, Germany’, The Asian Journal, 25 February. Available at https:// www.asianjournal.com/philippines/across-the-islands/backlash-ensues-after-ph-offersnurses-in-exchange-for-covid-vaccines-from-uk-germany/ (Accessed 10 November 2021). Morales, N. (2021) ‘Philippines Offers Nurses in Exchange for Vaccines from Britain, Germany’, Reuters, 23 February. Available at: https://www.reuters.com/article/uk-hea lth-coronavirus-philippines-labour-idUKKBN2AN0WV (Accessed: 16 December 2021). Salaverria, L. (2021) ‘Exodus of Nurses Alarms Private Hospitals’, INQUIRET.net, 20 October. Available at: https://newsinfo.inquirer.net/1504086/exodus-of-nurses-alarmsprivate-hospitals (Accessed: 16 December 2021). Santos, A. (2020) ‘Attacked & Underpaid: Medics in Philippines Battle Stigma, Virus’, Al Jazeera, 2 April. Available at: https://www.aljazeera.com/news/2020/4/2/attackedunderpaid-medics-in-philippines-battle-stigma-virus (Accessed: 16 December 2021). Thornell, C. (2020) ‘Why the US Has so many Filipino Nurses’, Vox, 30 June. Available at: https://www.vox.com/2020/6/30/21307199/filipino-nurses-us (Accessed: 16 August 2021).

7

An ageing society and a shrinking workforce pool How Japan is preparing to tackle an impending demographic time-bomb Radha Adhikari and Maria Reinaruth D. Carlos

Introduction Currently, in 2022, Japan has the largest elderly population (classified as people over 65 years old) in the world and has often been described as the “super-ageing society” (Hirano 2017; GoJ 2014; Muramatsu and Akiyama 2011). Ageing people require varied levels of support and care: ranging from needing help with daily activities, to more intensive, long-term care. This increases the demand for more resources, including a larger care workforce. At the same time, the country is experiencing a declining birth rate, which results in a shrinking workforce pool in the labour market. This has become a major challenge in care workforce recruitment and management. Over the past few decades, in order to attract adequate numbers of workers into the care of the elderly and long-term care sector in Japan, care home managers have been trying to promote long-term care work as a very specialised profession, and an important job.1 However, the shortage of care workers in general, and more specifically the Certified Care Workers (CCWs) or Kaigo Fukushishi, continues to remain a major challenge. Japan’s population growth is estimated to have peaked (at 127,319,802) in 2010, and has been declining steadily since. The total population is predicted to shrink further to 82,199,470 by 2050 (World Life Expectancy 2020; Muramatsu and Akiyama 2011). This phenomenon, a huge elderly population, and a shrinking number of younger workers, has been described as a “demographic time-bomb”, of an unprecedented magnitude, and is ticking faster in Japan than any other country in the world (McCurry 2015; Muramatsu and Akiyama 2011). This has serious implications, not only for the long-term and elderly care sector, but also on the nation’s whole economy, and on most other service sectors. It is evident that maintaining satisfactory population growth is vital for a country, both to sustain its economy, and also to provide adequate care for its ageing population. In line with the shrinking birth rate, a shortage of care workers has been predicted to reach a critical stage in 2030. The projection is that people currently in their mid-60s (the first baby boomer generation, or those who were born post WW2, between 1945 and 1964) will become elderly or reach 65 + years of age in DOI: 10.4324/9781003218449-8

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2030 (Muramatsu and Akiyama 2011). Many of them will be responsible for caring for their elderly parents, resulting in elderly people caring for their very elderly parents. More younger care workers will be needed to support these elderly people in their 80s and 90s. Based on the age profile of the current birth rate and population trends, the number of those who would provide support and care for this group of people is going to become even smaller than it currently is. The Japanese Nursing Association suggests that currently, on average, 2.5 adults support one elderly person, and this stock is predicted to decrease gradually to be 1.5 adults per elderly person in 2060. As the projected birth rate will continue to decline, it is a serious cause for concern, hence its being termed an impending “demographic time-bomb” (Japanese Nursing Association 2014). The National Institute of Population and Social Security Research (NIPSSR 2014, p.1) also reports: Japan is the most aged society in the world, with 24.1% of the population aged more than 65 years old in 2012, and this rate would further increase to 40% in 2060, and the increase of “oldest-old”, namely aged 75 and more would be more than double from 11% in 2010 to 27% in 2060. Naturally, the young people (aged 0–19), comprising 40% of the total population in 1960 is shrinking to 18% in 2010, and 13% in 2060. In the past decade, Japan has been exploring and adopting possible ways to deal with the care workforce shortage, and very carefully relaxing its immigration policy to invite foreign care workers to the country (Hirano 2017; Song 2015; Ogawa 2012). Along with other local recruitment strategies, one of the most active measures Japan has taken since 2008 is recruiting foreign care workers (and nurses) from neighbouring Asian countries, under the Economic Partnership Agreement (EPA) Scheme, and including foreign care workers in Technical Trainee and Student Schemes since 2017 (Hirano 2017; Song 2015; Ogawa 2012). In 2019, it also established the “Specified Skills Work Visa” programme, in which foreign care workers need to pass Japanese language and skills examinations prior to coming to the country (Carlos and Suzuki 2020). The government has also been focusing on the “care in the community” option, and making concentrated investments in the promotion of healthy ageing strategies (Song 2015). EPA candidates have been recruited from the Philippines, Indonesia, and Vietnam, then supported to complete CCW training, and to pass their licensure exams in Japan. On successful completion of both, they can obtain work visas. However, because of issues related to social integration and migrants’ family reunions in Japan, their long-term retention has not been as satisfactory (Hirano 2017; Carlos 2012). Therefore, this has not been seen as a viable solution for the projected long-term workforce shortage. Based on the lessons learned from the EPA scheme, in 2017, Japan decided to introduce the Technical Trainee and Students’ scheme from a wider number

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of countries in Asia. This too, has been criticised by healthcare labour market experts as a “myopic policy option” (Hirano 2017). The Government has been exploring various workforce management strategies, but a sustained strategy is still to be found.

Long-term social care insurance Since 2000, the cost of “ageing” care (a term often used to describe it in Japan) has been covered by long-term care insurance policies (GoJ 2014; Song 2015). Japan was one of the pioneering countries, in setting up dedicated funding for long-term, and for elderly care (Creighton-Campbell and Ikegami 2000). In this scheme, from the age of 40, people are required to contribute to a compulsory long-term care insurance. While the long-term care costs are covered by the insurance, service users are responsible for copayment, which is between 10% and up to 30% of the service costs, depending on service users’ incomes and ages. The local government is responsible for the management of all health and social care sectors, and the policy is to provide a seamless service to elderly people, from home help and support in the community, to home-based longterm care. There is a vibrant private sector involved in the health service and in elderly care provision, as well as offering long-term care insurance. However, according to Japanese social policy, since the institutional care costs are government-subsidised, private sector care providers should not aim to make a profit in running their businesses (NIPSSR 2014). While the Government closely monitors and controls the cost of health and social care, individuals can choose their service providers. Australia, Canada, and some countries in Europe and Asia, face similar population trends. In order to maintain the labour market, and to address the workforce shortage, in the past decade, many affluent countries have started exploring various workforce management strategies, namely attracting their workforce from international sources, and adjusting their immigration policies accordingly (Song 2015). As such, migrant care workers play an increasingly prominent role in providing care for the elderly population, not only in Japan but also in the wider global context (Cangiano et al. 2009; Ehrenreich and Russell-Hochschild 2002). Given this backdrop, this chapter discusses some of the findings of two studies on care workforce management situations in the elderly care sector in Japan.

Research context Two multi-sited qualitative studies were conducted between 2014–2016 and 2017– 2019, looking at the care workforce situation, particularly in the elderly care sector in Japan. In these, nursing and care workforce recruitment and management practices, with a specific focus international recruitment, management and retention of this workforce, were explored.

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The research team visited a number of health facilities (large city hospitals n=2; care homes n=6) in central Japan. Key stakeholders in hospitals (Matron n=2) and care homes (manager n=6), EPA candidates, nurses and care workers (n=10) were interviewed. As well as in-depth interviews, interactive focus group discussions (n=3) were conducted with EPA candidates and Filipino care workers working in the care home sector. Fieldwork was carried out in a number of stages. The first stage provided an opportunity to gain a general overview of the care workforce situation in central Japan. In order to gain deeper understandings of ageing care, and of migrant care workers in a caring context, the second stage of field work focused specifically on care of the elderly in the care home sector. This time a daycare centre for people with dementia was revisited. This was run in a traditional Japanese house, the second floor of which was a dementia café, where traditional tea ceremonies and gatherings were held. A total of six elderly care facilities, where migrant care workers were employed were visited: one in Kyoto, two in Osaka Prefecture, one in Tokyo, one in Nara and one in Nagoya. The research team also interacted with the care home managers of these six facilities, and the migrant care workers working there.2 Some of the key findings are presented below.

Ageing in Japan This section discusses how ageing is perceived, as explained by the care home managers, and the significance of care workers within the Japanese socio-cultural context. In an interview, a care home manager explained her view of care of the elderly, one which she suggested is believed to be widely shared in Japanese society: In Japan, ageing care is perceived to be deeply personal and individual: elderly people are highly respected in society, so providing them care is almost a ‘sacred work’. Also, this is because care workers have to directly deal with another human being, and must touch their bodies, they are thus directly involved in an ageing person’s private life, both by providing physical and emotional care and support – this all is an intimate and personal experience for both the care providers and the care receivers. People’s individual choice is highly respected, and families try hard to maintain socio-cultural values and norms whilst providing care for their ageing family members. (Interview, Care home Manager, Osaka, October 2014) As in most societies globally, in Japan, historically, female family members have provided the majority of care to ageing parents, and indeed to any family member living with a long-term condition. However, in recent years, because of changing family dynamics, due to more women entering the labour market (in a variety of employment sectors), and the predominance of the nuclear family, it has been difficult for family members to provide this type of

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care (Song 2015; Muramatsu and Akiyama 2011; Creighton-Campbell and Ikegami 2000). Therefore, support from the Government and other care institutions, outwith close family and relatives, has been critical to the provision of ageing and long-term care.

Current ageing care mechanisms As noted above, since 2000, ageing care in Japan has been carefully streamlined, with the provision of dedicated financial mechanisms, appropriate cadres of staff (CCWs), and care providers managed by local municipalities. Health care services are provided by a number of stakeholders: the government of Japan, private companies (such as the Toyota car manufacturing company which has its own hospital), and charity organisations, such as the Red Cross. Ageing and long-term care is not provided in hospitals, or any healthcare institution, by healthcare professionals, but by care workers in social settings (GoJ 2014; Japanese Nursing Association 2014). One of the main aims of the radical reform of the elderly care sector in 2000, with the advent of the long-term care insurance scheme, was to move care of the elderly and long-term care from a “medical model of care” to a “social model of care” (NIPSSR 2014; Creighton-Campbell and Ikegami 2000). Ageing care needs are categorised at seven different levels, depending on individuals’ physical (in)dependency, and their care needs. Support (at home or day care service) is described as being at levels 1 and 2; whereas institutional care spans levels 1 to 5 (commonly known as care need levels). The transition between the different levels of care needs, for ageing and disabled people, is designed to be seamless, well-coordinated and “joined-up”, and it is vital that all levels of care can be offered by the same group of institutional care provider(s) (Masui et al. 2019; Creighton-Campbell and Ikegami 2000). During the research fieldwork, study participants suggested that national care guidelines are clear, and are followed strictly by care homes, and care managers in the community. The idea was further emphasised, in simple terms, by a care home manager in his statement that: ageing is not medicalised here in Japan, and community-based care is now highly encouraged, as ageing is not a medical condition, but a natural process. (Interview, care home manager, Tokyo Japan, February 2016) A care home manager in Kyoto further explained how the elderly care sector works in Japan. She stated: Ageing care in Japan comes under social security system, separate from the medical/healthcare system. According to the government guidelines, there are seven levels of care needs. An individual’s care need is assessed by a team of professionals within the municipality, and appropriate

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Radha Adhikari and Maria Reinaruth D. Carlos action is then decided. Criteria, or guidelines, for assessing individual care needs are clear, and are rigorously followed. There are five major areas to consider while assessing individuals’ needs. [The assessment system is revised based on the number of minutes required for care. The initial assessment is also done by computer.]

She continued: the support system begins with home help and care in the community: illness prevention and the health promotion aspect of elderly care is highly valued and maintained. To begin with, people with care needs at ‘Level 1’, would receive a home visit service for basic support with daily living, and the system focuses on delaying individuals’ care needs progressing to ‘Level 2’ and beyond. When someone’s care needs do increase, they are then transferred to a group home, and maintain this level of health and individual independence for as long as possible. In a group home, elderly people will receive appropriate levels of support with their activities of daily living. If and when required, people are transferred from the group home to a nursing home, an intensive care nursing home, or to a hospice for care. (Interview, care home manager, Kyoto, Japan, February 2016) The support system for elderly people begins then with care in the community (support need level 1 and 2). It is very clear that illness prevention and health promotion principles are highly valued, and maintained as much as possible. For example, whilst speaking to a care home manager, his short and sharp response, referring to Japan’s “Gold Plan”, was: in Japan, we focus on healthy life expectancy and healthy ageing and healthy life [with much stress] not just life expectancy. (Interview, care home manager, Tokyo, February 2016) This care home manager was very specific, and emphasised the point that, in Japan, they are “not just interested in how long people live (life expectancy in general), but how healthily people live” or how healthy and fit elderly people are (healthy life).3 One very distinct, and indeed unique, characteristic of the ageing care and social security system in Japan is this emphasis on illness prevention and health promotion activities. In 2000, the Japanese Government implemented the above-cited New Gold Plan 21. A part of the long-term care insurance plan was to increase investing in keeping people healthy in the community (Song 2015). There has been increased state support for the elderly, as regards staying physically active while living at home. Government policy is to encourage health screening and promotional activities, and is targeted to those who are 40 years old and above. The idea of “healthy living” seemed to have been wholeheartedly adopted by people in

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Figure 7.1 People cycling in a busy street in Tokyo Copyright Adhikari

the community. For example, during the fieldwork in different cities, it was observed that there were always a significant number of elderly people cycling around the town, a very easily and perceived occurrence, and one not often seen on a similar scale anywhere else in the world. In October 2014, in order to fully understand the country’s nursing and care workforce situation, the research team visited two major teaching hospitals in the Kanto region. After discussions with hospital Matrons and managers about the ageing care workforce situation there, and international recruitment practices, if any, in those hospitals, it became very evident that they had not experienced any nursing shortages. They further informed the team that there are neither allocated elderly care beds, or elderly care units, so the hospitals do not have the issues of “bed-blocking”, or of creating hospital waiting lists, a phenomenon commonly known as “social hospitalization” (Holder 2014). This is one of the reasons why healthcare institutions express no major concerns about nursing, or healthcare professional, shortages. However, the elderly care sector reports a very different story, mainly as regards Kaigo Fukushishi shortages.

Care workers and the labour market situation in Japan There have been serious shortages of care workers, both CCWs and other care workers, in Japan. The job openings-to-applicants ratio, which is often used in Japan as an indicator of such shortages, rose to as high as 4.31 in 2019, in the care

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Figure 7.2 Job openings and application Ratio in Japan: Employment Referrals for General Workers in Japan Source: Japan Ministry of Health, Labour and Welfare (MHLW 2021) Downloaded from e-Stat Japan

work services sector. This means that there are 4.31 available jobs for every care worker seeking work. This is much higher than the average for all other sectors, which was only 1.45 in the same year; Figure 7.2 illustrates this further. CCWs are independent practitioners with a professional licence. The licensure examination is administered by the “Social Welfare Promotion and National Examination Center”, and CCWs are regulated by the Ministry of Health, Labour and Welfare. There is an association of certified care workers that helps promote the profession (JACCW nd). The latest survey of Japan’s Ministry of Health, Labor and Welfare (2021) estimated that, in 2020, there were an estimated 1,862,286 care workers, only 918,361 of whom were CCWs, working in the sector at that time.4 In order to fully appreciate the care workforce situation, the study team visited six care homes in urban, as well as rural, areas of central Japan, where long-term care for elderly and disabled people is offered. All six institutions had struggled constantly with CCW shortages, which they attributed to the areas being not very attractive to the local workforce. Indeed, Care Home Managers in smaller towns and rural areas have found recruitment and retention of CCWs a major challenge in the past decade, and expect it to become worse in the future. Rural areas are less attractive than urban centres for younger people to work as CCWs. A care home manager in a semi-rural area, in Osaka prefecture, shared his experience: Recruitment of care workers is a major challenge particularly for this company, also in Japan generally.5 Currently there are 4–5 care workers’ positions vacant in this care home and we have not been able to recruit staff and

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fill these vacancies. We are compelled to employ bank care workers, and they are more expensive than the regular staff. Vacancy advertisement and recruitment costs are very high. There are many care homes literally within a kilometre radius in this area, so competition [for staff recruitment] is very high. Many new private care homes have emerged in this area recently. … in a local paper here recently, one in five local job adverts are for care workers. Currently, recruitment situation is definitely worse than it was in 2008, before the global financial crisis. I feel that the economy is improving now (as of September 2014); various other business sectors are growing too, so people are attracted to work in other areas, but not in the care sector. Care work is not attractive in Japan, as it is labour intensive service and still not very well paid. Also, there is general agreement that people consider care work a difficult job, poorly paid compared to jobs in other sectors. So, it has been very hard to find an appropriate candidate, and also it is difficult to retain them. (Interview, care home manager, Osaka, October 2014) Clearly, the care home sector is growing to meet the demand for increasing numbers of elderly people, and there are simply insufficient numbers of younger people entering the care work profession. Another care home manager described a further major dilemma, as regards the work of care worker the Kaigo Fukushishi. Her main frustration was that CCWs are expected to perform almost a “sacred task”, in providing deeply personal and intimate care for an ageing person, and because, in their work, they are touching peoples’ bodies, but their salaries are low. She commented: CCWs are seen as voluntary or at least half-voluntary service providers. Salaries for care workers are not attractive compared to other professionals within the health and social care system. Care work is hard and stressful and very time consuming. (Interview, care home manager, Kyoto, February 2016) In this care home manager’s experience, care work is not sufficiently valued by society. Reported tension between understanding and accepting the meaning of care work was apparent. Discussions highlighted that family, and management, would like care work to be regarded as sacred work, and that it must be carried out without complaining, or expressing any dissatisfaction. It has been viewed almost as charity work. She also suggested that, modern-day institutional care has replaced what was regarded as “women’s work” within the family in the past, and was not valued at all, hence the lack of credit given to care of the elderly in institutions. Additionally, it is hard work. CCWs need to be skilled professionals, providing compassionate care to the frail elderly. A trainee foreign care worker working in the same care home with the above manager, stated her view:

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Care work is also very personal, and acknowledged as such in most sociocultural contexts, and care workers find this profession to be stressful, not family-friendly, and requiring much emotional labour. Care workers have to work unsocial hours, and are low-paid, in comparison to other professionals. The profession therefore has not been very attractive as a long-term career choice. As a result, the retention of care workers (both migrant and local) in this sector has become a major challenge.

Government strategies to tackle current Kaigo Fukushishi shortages As the title of the chapter suggests the shortage of care workers, particularly Certified Care Workers or Kaigo Fukushishi, is widespread across the Japanese long-term care sector, and has been recognised by the government. There are a number of strategies the government is currently exploring to tackle the issue. As discussed earlier in this chapter, in addition to the policies at national level, there have been immigration policy adjustments, involving the private sector in care provision. Care home managers are involved in international care worker recruitment and management practices.

Bilateral Economic Partnership Agreement Scheme In 2008, after a lengthy policy planning and negotiation with neighbouring countries, Japan recruited its first group of nurses and care workers from Indonesia, followed by recruitment from the Philippines from 2009 (Song 2015; Carlos 2012). Since then, there has been regular international recruitment of nurses and care workers in Japan from three countries: Indonesia, the Philippines, and Vietnam. This is a policy initiative, between the Japanese government and foreign government, to recruit foreign care workers (and nurses) to come and work in Japan as nurse or CCW candidates (or trainees) for three or four years (three - for nurses; four - for careworkers), with the possibility of one year’ extension. If they pass Japanese professional licensure examination, they can stay longer. Researchers (Ogawa 2012; Carlos 2012) have commented that this scheme is not entirely just about addressing care workforce shortages, but is also a way of maintaining international relationships with neighbouring countries, and exploring if this scheme offers any long-term economic benefits to both parties: to Japan as well as those countries sending care workforce, and other types of EPA candidates. However, from the engagement with care home managers and EPA candidates, it was found that, among other policy measures introduced to address the shortage of care workers in Japan, this scheme was the most talked about, high profile, and highly controversial (Ohno 2012).

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Further, the EPA scheme was the first initiative of the Japanese government to meet labour shortages through the recruitment of foreign workers, and is closely associated with the ageing and long-term care sector in Japan, as it was designed to address the care worker shortage there. Its high-profile status is due to its being a part of a comprehensive trade and investment agreement, and its being highly invested, publicised, and perhaps overly talked about, and researched (for example, Ogawa 2012). When visiting a care home in Tokyo, the care home manager stated “even the Emperor of Japan has become interested in this scheme”. Emperor Emeritus Akihito visited a care home, where EPA care workers were employed, to gauge the success of the scheme. This care home manager was involved in recruiting EPA care workers from abroad, and supporting them to obtain their Japanese CCW license. He commented: the Emperor came to our care home to see EPA care work candidates. He [the Emperor] interacted with them too. It immediately became national headline news, which helped us publicise our company and our work as well, we were in national television. (Interview, care home manager, Tokyo, February 2016)6 The level of public and political attention to the EPA schemes suggests that it is recognised, and valued, as an important policy measure, aimed at addressing the problem of labour shortages in the care home sector. In all six care homes, and in the two large teaching hospitals, the research team were presented with a large volume of teaching and learning materials, developed to support EPA candidates, and to help them prepare for their Japanese language and CCW licensure exam. It was quite evident that EPAs were well supported in language learning, as well as caring skills, in order for them to pass their exams. There has been significant investment in supporting EPA candidates, and they are very carefully managed. The CCW licensure exam consists of a Japanese language test as well as a caring skills test. However, most EPA candidates expressed their concerns that the CCW licensure exam pass rate is low, requiring multiple resits. Almost all informants suggested that this is due to the taught Japanese language test, as they have found it very hard to learn Japanese. It was evident from the discussion that EPA candidates are carefully managed by the Japanese Government. For instance, one of the informants, who was an EPA candidate, a Filipino care worker, explained that he was not able to pass his CCW licensure exam within the given time frame, and he had to return to the Philippines. On arrival home in Manila, he realised that his circumstances were not unique and that there were many other EPA candidates in the same position. Within a month of his return, all returnees (those who had not managed to pass their CCW licensure exam on Japan) were invited to the Japanese Embassy in Manila, and met by the Ambassador himself. He discussed their circumstances, and they were given one more opportunity to

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go to Japan, and he encouraged them to resit their CCW licensure exam. The care worker recollected: The Ambassador asked us if we wanted to come back to Japan and try our CCW licensure exam again. We were given options – to work in a Japanese company in the Philippines or to come to Japan as a Japanese language student. I wanted to have an intensive language course, which I felt was important to pass the exam, so I came back as a Japanese language student. (Interview, Filipino care worker, Kyoto, May 2017)7 Following the second attempt, this care worker passed his CCW licensure exam and started working in a rehabilitation hospital services facility (in the home care sector) in Japan. However, in a subsequent meeting, he indicated that he was not planning to continue in this post much longer. He found social integration in Japan very challenging, and he did not feel that he was fully accepted there. Eventually, he transferred to a nursing home in Yokohama that employs many Filipino care workers. One of the major criticisms of the EPA scheme is the low retention rate, the key reason being Japan’s very strict language and immigration policy (Vilog, Arroyo and Raquinio 2020). The professional licensure exams for CCWs and nurses are conducted in the Japanese language. Most migrant care workers and care home managers commented on the extreme difficulties EPA candidates face in order to pass these exams. If they are not able to pass their exams within a given time frame, their work visas are not renewed, and they have to return to their home countries. Having made a major investment in their recruitment and training, their return is a loss for both the Government and their employers. Despite considerable publicity and government efforts, this initiative has proven to be not fully successful in retaining migrant care workers in Japan. Poor retention appears to have been for two reasons: 1) low pass rates in the CCW Licensure exam, and 2) there is no clear family reunion provision for foreign care workers, and EPA candidates. Initially, EPA candidates are given two opportunities to take their CCW licensure exam. If they are not successful, they will not be eligible for visa extensions. Therefore, they will have to return home or go elsewhere to work. Some of those who have already passed this exam have also left, because of various other reasons, both those that are common among care workers, such as poor working conditions, low pay (compared to other affluent countries), and those specific to foreigners, such as deskilling, lack of support for family integration8 and lack of career progression.

Attracting foreign technical trainees (students) Since early 1993, Japan has been attracting workers, technical trainees, and students, from neighbouring countries in Asia, under a technical training programme, with the aim of transferring skills to, and promoting international

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cooperation with, developing countries and other regions (JITCO nd). This scheme, however, is highly criticised as a means of securing cheap labour in selected industries, such as agriculture, hotel management and tourism (The Mainichi Newspaper 2018). In 2017 the Government decided to open up this opportunity for foreign technical trainees in the care work sector too, and introduced the relevant immigration provisions (Hirano 2018). During the final stage of research fieldwork, the technical trainee in care work scheme was still very new on the ground. Some of the concerns about the technical trainee scheme, where foreign students would come to Japan to learn about, and work in, the ageing care sector, was about its long-term sustainability, and the attendant socio-cultural and language challenges, as had been experienced by EPA candidates. Study informants frequently suggested that, if the government is to consider this option, or explore, or even pilot this strategy, these important factors of long-term sustainability, language support and socio-cultural integration, immigration, and issues of family reunion for the migrants, should also be considered (Carlos and Suzuki 2020; Vilog, Arroyo and Raquinio 2020; Carlos and Adhikari 2017).

Attracting local candidates into the ageing care sector Interaction with the elderly care providers, particularly private care home managers during the fieldwork, indicated that they have made major coordinated efforts, and investments, to attract the younger generation, and more specifically males, into care work.9 Care home managers disseminate positive messages and images of young men working in the ageing care sector. During the fieldwork, the study team witnessed some advertisements, and promotion materials, of positive case studies, alongside photographs depicting male care workers in their workplaces, looking after elderly people. Such materials were also displayed in public places, such as university and college reception areas, and care home reception areas, and information booklets were distributed to the general public, and to university students. Care home managers reported that some major companies, involved in providing elderly and long-term care, have borne the production costs, and also been involved in the design of the written materials, and the care workers’ recruitment campaign. The profession appears to be almost glamourised in these books. Given that it was a new initiative, care home managers further commented that its impact was still to be seen. Some other smaller scale and local initiatives include care managers recruiting foreign residents living in Japan for a long time, the majority of them being foreign women, married to Japanese men, and living locally. One of the care home managers in a rural area, having employed almost all of the above strategies, was also trying this approach, and reported this “a partial success”, as these women lived locally and were usually looking for a job. For the past few years, the manager has trained about 20 such local women and offered them jobs. However, both the manager and the trainee care workers

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stated that it takes a very long time to learn the language and local culture, in order to become fully accepted by the recipients of the care. Overall, it can be said that in Japan, the attempt to solve the labour shortage in the care sector has become a joint effort of the Government and the private sector

Improve technology and services to meet the need of elderly people Commonly known as a “silver service business”, that is one dedicated to senior citizens, both in Japan and globally, these improvements have been perceived as a panacea for the current workforce challenges faced by the care of the elderly sector (Masui 2016). One of the study participants reported that the concept of silver service is quite vague, and covers a wide range of services. Some of the most common applications of modern technology seen in

Figure 7.3 Robot in nursing station in a care home in Osaka Copyright Adhikari

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Japan today are designed to help people with various activities, and interact with elderly people who feel lonely. This includes the use of robotic devices, such as Pepper-kun developed by SoftBank Robotics Corporation, and technology assisted care (Foster 2018). Robotic devices were noticed to be stationed around in various places in care homes in Osaka prefecture. During the field work, these were being tried as to their effectiveness, in supporting the needs of the elderly residents. Further, care home managers reported the development of pre-packed single portion meals and meal box lunches, by some Japanese small businesses, and indeed in the food industry, with the older citizen in mind. Widely available in supermarkets, and convenience stores, this is a rapidly growing business in Japan (Nippon.com 2015). Care home managers reported further examples of commercial products designed to assist elderly people. Car manufacturers, such as Toyota and Subaru, are exploring the possibility of designing a driverless car for elderly people (The Japan Times 2021). Other silver service businesses cited by participants include the design of holiday and leisure activities tailored to the needs of elderly people. Care home managers reported that Japanese businesses, such as the Panasonic company, are exploring healthcare technology. Hoists, and other lifting aids, have been piloted and tested for their suitability and benefit for this client group. These were currently being trialled in care homes. Such business trends are increasing. In order to tackle the care workforce shortages, it is also worth noting that those Japanese companies, specialising in modern technology, would appear to have conveniently vested interests.

Conclusion This chapter illustrates that, over the last two decades, the ageing and longterm care sector in Japan has received much-needed policy attention and political commitment. The government has been proactive in addressing the increased ageing care needs in the country, and has taken a comprehensive approach, that focuses on two key areas: 1) the provision of long-term care insurance (or financial planning) for the elderly and people with long-term care needs, and 2) the exploration of various workforce recruitment options, nationally and internationally, to ensure the current and future workforce gap is adequately addressed. Private sector care providers are actively involved in the provision of long-term care insurance and services. The care home sector is also involved in the international recruitment and management of care workforce, in exploring the possibility of modern technology. Meanwhile the manufacturing sector is exploring the uses of modern technology in long-term care and support provision. As regards the first key area, since 2000, the ageing care sector has been streamlined by the government to ensure adequate financial support is available to cover the long-term care costs. Currently, this sector has a dedicated funding mechanism, which is independent of the funding available for the

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actual health care. The fees or the service costs are covered by the insurance and, as the Government establishes the rates, care costs are uniform or standarised in all care homes. However, as in other countries with a fast-increasing elderly population, the burgeoning benefit payments are depleting the funds, previously largely dependent on contributions from the working generation. As the number of workers, or active economic contributors, decreases, and non-payments or defaults increase, how Japan will sustain increased ageing care provision remains of great concern (Masui et al. 2019). Secondly, realising the gradual shrinking of the workforce pool, and the increased demand for care workers, the Government has become proactive as regards to projecting future needs, and exploring various options to secure the current and future workforce supply in the care sector. Unfortunately, although international recruitment under the EPA and TT arrangement might appear a simple process, the long-term retention and management of a migrant workforce has proven to be complex. As argued in the literature, and discussed in this chapter, the longer-term retention of internationally recruited EPA candidates has not been as successful as expected (Carlos and Suzuki 2020; Carlos and Adhikari 2017). As well as international recruitment, there are local recruitment and retention initiatives, albeit on a smaller scale, that have been perceived as successful to a certain extent. Some of the positive moves have been in encouraging younger men to join this sector, in local recruitment and retention initiatives. However, it has also been evident from the discussion above that younger people do not consider this sector as a long-term career option, due to the nature of the work, the long and unsocial working hours, the poor salaries and lack of other benefits, even though care of the elderly has been seen (and been promoted by some care home managers) as a very special and “sacred” job in Japan. There are key factors in the successful retention of care workers in a country. A country’s professional licensing regulation and immigration policy is one such factor, including opportunities for family integration for migrant workers (Carlos and Adhikari 2017). It is very evident from the discussion throughout this chapter that Japan, in comparison to the UK and the US, has remained fairly conservative in its immigration policy, and migrant management style, throughout its history. As a result of its strict immigration policy, particularly regarding migrant workers’ family integration, many EPA candidates return home to be with their families, or move to another destination country such as Canada, even those who have successfully passed their CCW licensure exam (Carlos and Adhikari 2017). Yet, Japan has not developed a clear policy as regards to family integration for its migrant workers (Nakamura 2013). It is important also to appreciate that most migrants in Japan appear to be a group of young people. They look for jobs that offer them better salaries and other benefits, with professional development opportunities, nationally or internationally (Carlos 2012). Based on the discussion above, this chapter proposes that the Japanese government should explore,

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and adopt, a more liberal policy in terms of the international recruitment and management of its care workforce, and crucially also develop and implement a family integration policy, which will support the retention of a migrant workforce in Japan. One of the key messages of this chapter is that the small-scale local recruitment and retention, in rural as well as urban areas, has become a success story in some parts of Japan. The care home managers’ meticulous approach to workforce planning, recruitment, and retention of the local workforce, appears impressive but, as highlighted above, many challenges remain. While such care workforce recruitment and retention strategies are very contextual in Japanese society, some of the positive lessons could be adopted by other healthcare systems facing similar challenges globally. In terms of the international recruitment and management of care workers, initially, the labour market in Japan was managed and controlled by the Government authority, using a bilateral Economic Partnership Agreement, which has proven successful in protecting migrant workers’ rights, and avoiding exploitation in recruitment and employment processes. However, with the limitations of the scheme, particularly in terms of meeting the increasing demand for care workers at home, to what extent the Government can monitor the new recruits, and ensure their welfare, remains a considerable challenge (Carlos and Suzuki 2020). In conclusion, if care work is considered as a valued, and almost “sacred profession”, then care workers’ views should be considered and translated into policy. Increasing salaries, improving working terms and conditions, and creating long-term career pathways for this workforce, and family integration facilities for migrant workers, will attract candidates to this sector, and promote staff retention. This would elevate the social status of this profession and acknowledge the valuable contribution of foreign care workers to the care sector in Japan.

Notes 1 It was revealed in our discussion with care home managers that dealing with the human body, and supporting people in intimate and personal care, is almost a sacred job. This is further discussed below. 2 Ethical clearance was obtained from each individual institution we visited, and the informants we met during data collection. The purpose of our research and the aims of our visit to these ageing care institutions were fully explained to all appropriate authorities, and consent was obtained before we interacted with each migrant care worker, or local care and health service managers. The research team crosschecked the research data for its validity. 3 There is also called the “Orange Plan” now, to take care of elderly with dementia within the community. 4 https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/hukushi_kaigo/seikatsuhogo/shakaikaigo-fukushi1/shakai-kaigo-fukushi6.html. 5 This care home manager further explained the situation. He reported that there was a general shortage of care workers (not only CCWs), although the shortage is worse

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for CCWs. While there is a preference to employ CCWs, it is difficult because of the required education and licence. As a result, CCWs are still a minority in many care homes, with most of the staff receiving only minimal training, and being uncertified. However, the local news or press articles were not available to include in this chapter. At that time, there was no visa issued to care workers other than via the EPA, but, since 2017, the government has introduced a Technical Trainee Student Visa for foreign care workers. For example, the dependent of an EPA certified care worker can only work for a maximum of 28 hours a week. Interview with care home manager in Kyoto, in November 2016.

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The Japan Times (2021) ‘Graying Japan Drives Automakers to Redesign Cars for Seniors’, Available at: https://www.japantimes.co.jp/news/2021/01/19/business/ corporate-business/cars-older-drivers-japan/ (Accessed: 15 February 2022). The Mainichi Newspaper (2018) ‘Shrinking Japan: Woes of Technical Trainees Spur Response from Some Firms’,21 November. Available at: https://mainichi.jp/eng lish/articles/20181121/p2a/00m/0na/002000c (Accessed: 16 February 2022). Vilog, R.B.T., Arroyo, M.K.H.D. and Raquinio, T.G.G. (2020) ‘Empowerment Issues in Japan’s Care Industry: Narratives of Filipino Nurses and Care Workers under the Economic Partnership Agreement (EPA) Labour Scheme’, International Journal of Asia Pacific Studies 16 (1), pp. 39–69, https://doi.org/10.21315/ijaps2020.16.1.2 WORLDLIFEEXPECTANCY (2020) Interactive Map. Available at: https://www. worldlifeexpectancy.com/japan-population-pyramid (Accessed: 8 August 2020).

Conclusion: Nurse migration in Asia Current challenges and opportunities Evgeniya Plotnikova and Radha Adhikari

This volume has offered an overview of the rapidly changing and evolving nursing workforce management policy; current practices in nursing and care worker preparation and management at home, during and before the Covid-19 pandemic, and patterns of international recruitment and migration of this workforce in the Asian context. Country case studies of health worker cross-border mobility have revealed various actors with vested interests in nurse and care worker migration and workforce management. These actors are the states, both sending and receiving; professional institutions, such as professional regulatory bodies and nursing schools, both public and private; migration brokers, such as recruitment agencies, foreign language training institutions, visa application processing agencies, and individual migrants themselves. The roles and functioning of these actors have also been closely examined. Some Asian countries, both sending and receiving, seem to adapt opportunistic and pragmatic approaches to workforce management at home, and to the international recruitment of nursing and care workforces. When they see the economic benefits of nurse and care worker migration and emigration, the governments actively promote the process by establishing friendly relations, and entering into bilateral agreements with other states, attracting foreign graduates, tailoring visa and emigration processes, and/or facilitating crossborder mobility of home-educated health care professionals. This is seen in the partnerships between the Gulf States and India, and between Japan and the Philippines for example. At the same time, when the states are under political or economic pressures to “manage” migration, the governments introduce rather drastic measures, such as placing “bans” or “caps” on emigration (as discussed about the Philippines in Chapters 4 and 6), or implementing stringent immigration regulations (as discussed in Chapters 2, 5 and 6), often making individual migrants their scapegoats. Professional institutions, as well as migration brokers, also play a vital role in international nurse and healthcare professional migration (Adhikari 2019; Kingma 2006). These institutions have their own vested interests, and they often play dubious and dual roles, as migration facilitators and as gatekeepers, in setting up migration barriers. For example, the country case studies (such as in India and the Philippines) in this volume witness nursing colleges increasing or DOI: 10.4324/9781003218449-9

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reducing their education capacity, and professional regulatory bodies adjusting their licensing policies to allow or prohibit the international migration of healthcare workers (see Chapters 2, 4 and 5). Furthermore, there seems to be a lack of consistent and coherent approaches to standardise nursing education nationally and internationally, as illustrated with examples from the Philippines and India in Chapters 1, 2, and 4. There is also an absence of provision of conditions for foreign-educated nurses to make the full use of their talents, nursing skills and knowledge in destination countries, such as in Singapore and Japan (seen in Chapters 4 and 5). The Chinese Nursing Association, on the other hand (discussed in Chapter 3), has been expanding its influence across Asian countries and beyond by engaging with foreign nursing bodies, promoting international mobility of nurses to some extent. The most important actors are the migrant nurses and care workers themselves and their families. In most cases, prevailing social and structural inequalities propel them to migrate. In this volume, as clearly illustrated in the context of India and the Philippines, after investing substantial amounts of resources in professional education, nurses look for attractive job vacancies nationally or internationally. When they are not able to find their desired positions at home, then they consider an international move, seeking professional development and economic opportunities, to shape a better future for themselves and for their families (as discussed in Chapters 1, 2, 4, and 5). Unfortunately, even after making international moves, career paths for nurses do not always turn out in the desired direction. Many nurses face discrimination at their workplaces, and they often struggle to find suitable opportunities for professional development, and career progression, in destination countries. Empirical studies presented in this volume on Filipino migrant nurses in Singapore and in Japan, and Indian nurses in GCC countries, clearly illustrate this phenomenon. Sadly, this is the reality for many migrant nurses and healthcare professionals in most destination countries globally (Adhikari 2019; Kingma 2006). A huge disparity in health workforce distribution, service provision, and accessing health services nationally, regionally, and internationally is well reported in the literature. Compounding this are disparities in wages, working conditions, career development opportunities, and retirement prospects, for healthcare professionals, mainly between affluent and low-income countries. This disparity is determined primarily by a country’s economic status and political commitments. Health workforce experts suggest that most countries globally (both affluent and low-income) are not investing enough in human resource development and retention in the health sector, and that their long-term workforce planning is poor (WHO 2020; Mackintosh et al. 2006). This, then leads to the workforce shortage. When affluent countries experience acute shortages, they often resort to international recruitment, which has only been a patchwork solution for them, escalating further inequalities in workforce distribution and service provision. For example, this has been very evident in the UK

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presently, in order to address the considerable shortfalls, the Health Boards across the UK National Health Service (NHS), are actively recruiting nurses from international sources to deal with post-pandemic health service backlog (Government of UK 2022; Mitchell 2022). After examining those key actors and the role they play, a critical issue has emerged, which is the urgent need for a proper health workforce governance framework covering education, employment, retention, and safe and respectful international recruitment and migration policies, at national and international levels. Important steps towards establishing such a framework have already been made at the international level, for instance, the WHO Global Code of Practice (2010); the International Platform on Health Worker Mobility (2017); the Global Strategy on Human Resources for Health; Workforce 2030 (2016) and the Global Compact for Safe, Orderly and Regular Migration (2018). However, unfortunately, the implementation of these international frameworks still remains a challenge at national levels. Often sovereign states prioritise a national security discourse, to retain and, crucially, protect their autonomy in determining their own approach to health workforce management and immigration, and border control policies, in a paternalistic fashion (Betts 2008). Scholars have sufficiently discussed the need for states to invest in human resource development, and also to develop a coherent and consistent approach to migration governance, taking into account the emerging global health workforce migration patterns and contexts (Betts 2008). This volume further identifies this need, and stresses that international nurse migration, and more broadly, healthcare professional migration, should also be an important aspect of national health workforce planning and management policies. As illustrated in the case studies in this volume, cross-border mobility of health professionals and national health workforce policies, including planning, education, employment, and retention, have become increasingly interconnected. For instance, poor national health workforce planning and management strategies may lead to labour shortages in one country and the need to recruit from abroad. Further, poor employment conditions and career prospects in the countries of origin become a driving force for the outmigration of many skilled professionals. Therefore, the impact of the cross-border mobility of healthcare professionals should be taken into account when developing and implementing any national health workforce management policy. Furthermore, when it comes to health workforce planning, it is not sufficient to look only at the factors affecting the supply and demand for healthcare professionals at the national level, but the global context of health worker migration should also be considered. Therefore, it is vital to have a multi-sectoral and multi-disciplinary approach to health workforce policies, which includes the following components, namely 1) accounting for the impact of cross-border mobility patterns of healthcare professionals on the national health workforce stock; and 2) developing and implementing comprehensive migration policy guidelines that address migrant nurses’ rights and welfare, as part of any national health workforce strategies.

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The Covid-19 crisis and its impact on the global health system and international nurse migration Currently, almost all health and social care systems globally are experiencing the devastating impact of the Covid-19 pandemic on their workforce. The pandemic has depleted not only the total workforce stock but also negatively impacted on their health and well-being, crippling the already fragile health and social care workforce situation. Covid-19 has exhausted resources, and it has shattered the health infrastructure locally, nationally, and globally, leaving a huge emotional scar on health professionals (Covner et al. 2021). It has been estimated that the Covid-19 pandemic has taken more nurses’ lives than the First World War (Keles, Bektemur and Baydili 2021). The International Council of Nurses (ICN) reported that a significant number of healthcare professionals, both frontline nurses and other care staff, have been seriously ill and that many have lost their lives to Covid-19 (ICN 2020). Stories of frontline healthcare professionals suffering from post-traumatic stress disorder due to the pandemic are widely reported (Barello et al. 2020). This devastation is global, and almost all actors involved in international nurse migration have been affected. However, the full impact of the pandemic on the nursing and health care workforce is still to be seen and reflected upon. From the beginning of the pandemic, almost all countries closed their borders, and transportation was halted totally for many months in 2020 and has remained restrictive throughout 2021. Most migrant workers, including healthcare professionals, have been stranded abroad in Asian countries, and globally. While migrant workers working in hospitality, and in service and other commercial sectors have lost jobs and livelihoods during the Covid-19 pandemic, some migrant workers, such as nurses and care workers in Japan, have actually found more jobs as the pandemic created an increased demand for healthcare workforce (Kajimoto 2021). There has not yet been any systemic research conducted to look at health workers’ mobility during the pandemic, but available news reports, and anecdotal evidence, suggest that health workers’ mobility continued to some degree. As highlighted in Chapter 2 by Walton-Roberts and Khadria, Indian nurses travelled to the GCC countries to fill the increased number of vacancies created by the pandemic. Historically, in a pre-Covid-19 context, when countries (often the affluent ones) were faced with an acute shortage of healthcare workers, they would swiftly resort to international recruitment to deal with the situation. They were not able to do so during the pandemic, primarily due to the Covid-19 related travel restriction and bans. For instance, the prominent nurse and care worker supplying country, the Philippines (as discussed in Chapters 4 and 6), has placed a cap on how many nurses would be allowed to leave the country, as more nurses were needed there to manage the crisis at home. Apart from restrictive measures, such as migration bans introduced during the pandemic, prior to this crisis, both source and destination countries in

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Asia used various policies and regulations to facilitate migration and to attract and manage internationally educated healthcare professionals. Such strategies related to international recruitment and the management of healthcare professionals are focused on adjusting immigration regulations and negotiating bilateral agreements on labour recruitment.

Bilateral agreements and MoUs in the Asian context Chapters in this volume have illustrated how the various states in Asia have initiated bilateral and multilateral trade and Economic Partnership Agreements (EPAs). Some of these bilateral agreements (such as the EPA scheme in Japan and the Philippines and a Memorandum of Understanding (MoU) between India and the Gulf States) are aimed primarily at promoting economic growth and development, which create favourable provisions for crossborder mobility of goods, services, and people, including the promotion of medical tourism. Some trade agreements amongst ASEAN (Association of Southeast Asian Nations) countries and SAARC (South Asian Association for Regional Cooperation) countries have a Mutual Recognition Agreement (MRA) on nursing, dentistry, and medical qualifications to promote collaboration in professional education and practice. Another example of the economic development strategy, with the potential to significantly influence international nurse migration in the future, is China’s ambitious Belt and Road Initiative (BRI), which has already demonstrated its impact on internationalisation in nursing and care worker education (as highlighted in Chapter 3). Furthermore, China has the largest stock of nurse graduates and has the potential to become the major nurse-supplying country in the world (WHO 2022; Fang 2007; Kingma 2006). Japan has also increased its global outlook as an attractive destination country for foreign healthcare workers, by expanding its international recruitment capacity since 2017–18 and inviting foreign technical trainee students into the care work sector from neighbouring countries in Asia, including China (Carlos and Suzuki 2020; Hirano 2018). Although various bilateral and multilateral agreements offer a common framework to address and manage issues associated with the international migration and recruitment of health professionals, many challenges in managing health worker migration remain. Migrant receiving countries, such as Japan, Singapore, and the countries in the Gulf States, have developed and introduced international recruitment strategies, entry routes, and visa categories for foreign healthcare workers. However, the implementation of those regulations is complex and not always straightforward. Often the complexity of the existing regulations, and the stringent entry visa requirements, lead to a situation where migrant healthcare professionals, both nurses and care workers, end up choosing “short-cuts”, via arguably easier routes for emigration, but not necessarily to their desired destinations, or they have to take up lowerlevel jobs in the care sector abroad. Many aspirant nurses fall into the so-

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called “migration trap”. Carlos in Chapter 4 and Navallo in Chapter 5 have discussed this phenomenon in detail. Further, migrant nurses and care workers in the Philippines and India often have to negotiate various hurdles, and they often have even prepared themselves to accept downward professional mobility, with qualified professional nurses accepting care worker positions. Some Filipino nurses end up accepting non-nursing positions, such as working in call centres or as language translators in the medical tourism sector, or they migrate as students. Carlos and Navallo examine how Filipino migrant nurses are becoming deskilled in Singapore and in Japan’s elderly care sector. This has also been a global health workforce concern, as there is a significant wastage of these resources (Adhikari 2019; Kingma 2006). As the cases in this volume demonstrate, nurses and healthcare professionals regularly face various social and professional hurdles, not only in the destination countries, but also in their countries of origin. These include a lack of, or poor, career progression pathways, discrimination at the workplace, and overall mismanagement of this workforce. Thus, a significant proportion of nurse graduates in the Philippines, India, China, and Nepal, cannot find suitable nursing positions in their home countries, and in the destination countries, such as Japan, Singapore, and Thailand. As the empirical data presented in the chapters suggest, migrant nurses and care workers experience difficulties throughout their migration journeys: from pre-migration decision-making, then during their journeys, and thereafter at their jobs, and their futures remain unclear. Meanwhile, destination countries seem to be interested primarily in filling the workforce gap but are less clear about migrant workers’ rights, welfare, and career development pathways. Another theme that emerges strongly from the discussion in this volume is the importance of professional recognition and autonomy. As the discussion in Chapters 3 and 4 demonstrates, Chinese nurses consider leaving their profession, and PENs in Singapore face a lack of career progression pathways and aspire to find new jobs in new destinations, mainly because of the lack of professional recognition and autonomy either in their countries of origin or in some of the destination countries. This raises a crucial question of how to properly manage this workforce and, more specifically, the need to explore ways to support nurses to promote their professional autonomy. There is perhaps a great need for targeted professional development opportunities for all nurses if health systems are to improve staff retention. Further, workforce retention has been a real and on-going challenge for most health and social care systems in Asia and globally. Carlos (Chapter 4) in this volume highlights the need for all states to address this issue, by developing clear career pathways for migrant nurses and care workers, as an important component of migrant workforce management and migration governance. For all these reasons, the need for proper migration governance and management has never been so urgent. International recruitment and migration of nurses and care workers remain central to any health policy debates in the countries discussed in this

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volume. Some countries are preparing to send nurses abroad, and others regularly recruit nurses and healthcare workers from overseas. Quite often, nurses make multiple moves, and Asian countries become steppingstones for further destinations, illustrating nurses’ current active mobility in Asian countries. The possibility of the migrant healthcare professionals’ returning home is not adequately discussed in health policy literature. Case studies presented in this volume from China (Chapter 3) and India (Chapters 1 and 2) suggest that international migration of nurses is not a one-way flow or an irreversible type of brain drain but a dynamic process, which also includes return migration. The process of return migration of nurses and other categories of healthcare professionals who wish to go back should be better managed to facilitate professional integration and improve health service provision. Yet, there is no coherent policy that is beneficial to all stakeholders: be they sending and receiving states’ healthcare systems or migrant nurses.

International frameworks and campaigns relevant to health worker migration and management The international recruitment of nurses and healthcare professionals from low-income countries to affluent countries has been seen as a brain, or resource, drain, and ethical concerns have been raised since the 1970s (Mejia 1978). It has only intensified in recent decades. In response to this, the WHO developed a Global Code of Practice in 2010 to promote ethical recruitment, but its implementation, has not been consistent. Global and regional shortages of nurses, and other healthcare professionals have reached a critical point, and it is expected to continue. At the same time, the United Nations (UN) has an ambitious plan to achieve Universal Health Coverage (UHC) by 2030 as part of the Sustainable Development Goals (SDGs) agenda. An adequate supply of a nursing workforce globally is critical to achieving UHC. Further to this, recognising the workforce recruitment and management challenges that most countries are currently facing, the WHO declared 2020 as the “International Year of the Nurses and the Midwife” (also celebrating the 200th anniversary of Florence Nightingale’s birthday), focusing on how to make nursing and midwifery an attractive profession, and promote retention to meet UHC by 2030. In declaring “Nurses and Midwives’ Year 2020” WHO prepared a comprehensive report on the “State of the World’s Nursing 2020”. The ICN and the WHO jointly planned the “Nursing Now” Global Campaign (2018–2020) (WHO 2020). This was for professional solidarity and to improve its professional image, linking this with achieving UHC by 2030 (as a part of the SDGs). Just as the campaign was launched, with its various activities and strategies in place, the Covid-19 pandemic hit the world, disrupting most of the activities planned for 2020, as resources were diverted towards the Covid19 response.

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Post-Covid-19 health workforce challenges and opportunities At the time of preparing this manuscript, the current Covid-19 pandemic is lurking around the world in different forms, with no sign of its ending, and with little understanding of how the post-Covid-19 situation will unfold. Therefore, it is difficult to speculate a post-Covid-19 “new normal” scenario for the migration of nurses and care workers. However, the pandemic has clearly highlighted the value of a nursing and healthcare workforce in the functioning of the health system and in saving peoples’ lives. Most importantly, the pandemic has illustrated that the healthcare system cannot function without a strong and properly managed workforce. After examining the current context of the nursing workforce and nurse migration in Asia, this volume makes two concluding points. Firstly, valuing the nursing and care work profession will lead to the key players being recognised – all nurses and health care workers nationally and internationally. This will improve the professional image and retention. Secondly, there is an urgent need to have a coherent, functional, and less exploitative strategy for governing health professional migration.

Valuing nursing and care work With changes in healthcare technology and in global population demography, with the consequent increase in long-term health conditions and emerging new global health challenges, the professional scope of nursing has expanded, and the demand for more nursing and healthcare professionals is growing. At the same time, the attraction towards nursing and care work (as a career choice) in affluent countries is declining. It has been extensively discussed how nursing and care work, have been chronically unvalued and underpaid. The empirical data presented in this volume suggest that care work is the source of high levels of physical and emotional “wear-and-tear” for the care providers. Because of this, as Navallo’s study findings highlight (Chapter 5), migrant nurses and care workers feel that care work should not be a lifelong profession. Similarly, scholars have argued that care work requires a high level of emotional intelligence and a caring and compassionate attitude, which demands a huge amount of emotional labour (Rolfe 2020; Kelly 2020). Precisely for these reasons, the recruitment and retention of local nursing and care workforces have been challenging, particularly in the elderly care sector in affluent countries. As a result, this sector often ends up recruiting foreign care workers. As seen in Chapters 5 and 7, in Japan, the value of care work has been recognised by making this a licensed and fully autonomous professional discipline, which is stream-lined to support people with long-term health conditions. In this respect, there is a valuable lesson for other countries to learn, which would perhaps make care work an attractive profession. Other countries in Asia, and indeed throughout the world, need to consider this. Making this profession attractive should be a global health priority.

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While exact data on the current nursing workforce affected by the pandemic is lacking (ICN 2020), the global nursing workforce stock is likely to deplete due to the deaths, long-term illnesses, fear, and workforce burnout, all stemming from the Covid-19 crisis. It is critical to pay attention to the well-being of this workforce. Further, migrant nurses and care workers have been found to be doubly vulnerable during the pandemic, and it is important for all the states involved in the international recruitment of healthcare professionals to protect their well-being. Finally, it is vital for health and social care systems to have a sustained supply of nursing and care workforces across the world. As outlined in the WHO report (2020), the critical role nurses play must be recognised, for nurses are vital in making a triple impact: achieving SDGs, Universal Health Coverage, and gender equality and women empowerment. Nursing and care work need to be recognised and valued at local, national, and international levels, whether the workers are local or migrant, in order to adequately staff the health and social care sector.

Global health governance and migration governance It has been very clear, throughout the discussion in this volume, that international migration is growing in magnitude, as we live in a deeply interconnected world. Due to changes in population demography, declining birth rates, and people living longer with long-term health conditions, changes in healthcare technology and the economy, the demand for healthcare professionals continues to grow. This means international migration will continue to increase. With increased mobility, issues such as labour rights, justice, ethical recruitment, and management have already become recurring concerns. While there are many positive aspects of international nurse and care worker migration, negative implications include migration contributing to a brain drain, or resource drain, from already vulnerable economies and societies to rich countries and the exploitation of migrant workers by host societies and employers. These two negative aspects need to be addressed by preserving and reinforcing the balance between migrants’ labour rights and their rights to freedom of movement on the one hand, and patients’ rights to appropriate care, on the other (Plotnikova 2011). Therefore, ensuring coherent and consistent implementation of international policy guidelines at both local and national levels should become a priority in the current discourse around health worker migration and health system functioning. Similarly, the international mobility of nurses and care workers, as a migration issue, needs to be included in the global health and migration governance agenda. Global health governance and global migration governance need to work collaboratively to make health worker migration safe, orderly, and less exploitative, and for the greater benefit of everyone. For this, there is a need to address existing structural inequality. Scholars have suggested that affluent countries, which have recruited nurses and healthcare professionals from low-income countries, should compensate those countries towards workforce development (Mackintosh et al. 2006). In recent years, there have been some initiatives to address this issue. For example, Germany has attempted to invest in nursing workforce development in

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Eastern European source countries – from where nurses migrate to work in Germany (WHO 2020). Perhaps Japan, Singapore, and other major recruiters in Asia (and Europe, North America and globally) should consider a similar strategy. We have seen numerous actors involved in international nurse migration: both governmental organisations and non-governmental and international actors, such as civil society organisations, faith-based organisations, and UN organisations, amongst others. All actors are highly important as regards global health and global migration governance. Although some progress has been made with the WHO Code (2010) on the responsible and ethical recruitment of health personnel, there are still challenges to its effective and comprehensive implementation. Finally, and most importantly, addressing the issues of structural inequality, fairness, and respect is vital. Fairness in health service provision and resource distribution, and fairness in migration and labour rights are critical in health workforce retention. This should be considered by all stakeholders at local, national, and international levels. Until all global actors and countries work together to address the workforce imbalance, the negative implications of cross-border mobility will continue.

References Adhikari, R. (2019) Migrant Health Professionals and the Global Labour Market: The Dreams and Traps of Nepali Nurses, Routledge. Barello, S., Palamenghi, L. and Graffigna, G. (2020) “Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian Covid-19 Pandemic”, Psychiatry Research 290, 113129. Available online at: https://www.science direct.com/science/article/pii/S0165178120311975 (Accessed 28 October 2021). Betts, A. (2008) Global Migration Governance, Working paper (2008/43) published in Global Economic Governance Programme, Department of Politics and International Relations, University of Oxford. Available at: https://www.econstor.eu/bitstream/10419/ 196305/1/GEG-WP-043.pdf (Accessed 24 November 2021). Carlos, M.R.D. and Suzuki, Y. (2020) “Japan’s Kaigoryugaku Scheme: Student pathway for care workers from the Philippines and other Asian countries”, in Y. Tsujita and O. Komazawa (eds.), Human Resources for the Health and Long-term Care of Older Persons in Asia. Jakarta: ERIA, pp.1–33. Covner, C., Raveis, V.H., Van Devanter, N., Yu, G., Glassman, K. and Ridge, L.J. (2021) “The psychological impact on frontline nurses of caring for patients with Covid-19 during the first wave of the pandemic in New York City”, Nurse Outlook, 69, pp. 744–754. Fang, Z. (2007) “Potential of China in global nurse migration”, Health Service Research, 54 (2), pp. 74–84. Global Compact for Safe, Orderly and Regular Migration (2018). Available at: https:// refugeesmigrants.un.org/sites/default/files/180711_final_draft_0.pdf (Accessed 27 February 2022). Government of UK (2022) Memorandum of Understanding between the Government of Nepal and the Government of the United Kingdom of Great Britain and Northern Ireland on the Recruitment of Health Care Professionals, policy paper. Available

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at: https://www.gov.uk/government/publications/memorandum-of-understandingbetween-the-uk-and-nepal-on-the-recruitment-of-healthcare-workers (Accessed 25 August 2022). Hirano, Y. (2018) “Securing Asian care workers in the era of globalization: Care workers entering Japan under economic partnership agreements”, Japanese Sociological Review, 68 (4), pp. 496–513. doi:10.4057/jsr.68.496. ICN – International Council of Nurses (2020) “Press Information”. Available at: https:// www.icn.ch/news/icn-confirms-1500-nurses-have-died-covid-19-44-countries-andestimates-healthcare-worker-covid (Accessed 25 October 2021). Kajimoto, T. (2021) “Pandemic opens door to switch jobs, but pay not rising much”. Reuters. Available at: https://www.reuters.com/world/the-great-reboot/pandemicopens-doors-switch-jobs-japan-pay-not-rising-much-2021-10-22/ (Accessed 22 February 2022). Keles, E., Bektemur, G. and Baydili, K.N. (2021) ‘Covid-19 deaths amongst nurses: A cross-sectional study”, Occupational Medicine, 71, pp.131–135. Kelly, D. (2020) “Death, dying and emotional labour: Still relevant after all these years”, Nursing Standard, 35(10), pp. 95–98. doi:10.7748/ns.35.10.95.s42. Kingma, M. (2006) Nurses on the Move: Migration and Global Health Care Economy. ILR Press an Imprint of Cornell University Press: Ithaca and London. Mackintosh, M., Mensah, K., Henry, L. and Rowson, M. (2006) “Aid, restitution and international fiscal redistribution in health care: Implications of health professionals’ migration”, Journal of International Development, 18, pp. 757–770. Mejia, A. (1978) “Migration of physicians and nurses: A world-wide picture”, International Journal of Epidemiology, 7 (3), pp. 207–215. Mitchell, G. (2022) “England’s CNO says 50,000 more nurses ‘no longer enough’”, Nursing Times. Available at: https://www.nursingtimes.net/news/workforce/englands-cno-sa ys-50000-more-nhs-nurses-no-longer-enough-22-03-2022/ (Accessed 2 June 2022). Plotnikova, E. (2011) “Cross-border mobility of health professionals: Contesting patients’ right to health”, Social Science and Medicine, 74, pp. 20–27. Rolfe, H. (2020) “Care work is undervalued and underfunded, but this has nothing to do with immigration”, research blog post. Available at: https://blogs.lse.ac.uk/brexit/ 2020/02/24/care-work-is-undervalued-and-underfunded-but-this-has-nothing-to-dowith-immigration/ (Accessed 27 November 2021). The Global Strategy on Human Resources for Health Workforce 2030 (2016) Available at: https://apps.who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf (Accessed 27 February 2022). The International Platform on Health Worker Mobility (2017) Available at: https:// www.who.int/publications/m/item/the-international-platform-onhealth-worker-mobility (Accessed 27 February 2022). WHO – World Health Organization (2010) Global Code of Practice on the International Recruitment of Health Personnel. Available at: https://www.who.int/hrh/migra tion/code/WHO_global_code_of_practice_EN.pdf (Accessed 14 February 2022). WHO – World Health Organization (2020) State of the World’s Nursing, Investing in Education, Jobs and Leadership. Prepared jointly by WHO, ICN and Nursing Now. WHO – World Health Organization (2022) The Global Health Observatory. Nursing Personnel. Available at: https://www.who.int/data/gho/data/indicators/indicator-deta ils/GHO/nursing-personnel-(number) (Accessed 23 February 2022).

Index

Abrigo, M. and Ortiz, D.A. 115 Abu, B. 78 ADB – Asian Development Bank, 6 Adhikari, R. 3, 11, 155, 160 ageing 5, 55–56, 135; ageing (super-ageing) in Japan 136–8; ageing (of nursing and care) workforce 56; see also population demography and demographic time bomb agreement (on protecting rights of migrants), 41–3, 126, 143–44, 151; see also bilateral agreement Aiken, et al. 60 Al Talabani, et al. 38 Amrith, S. 26 Anand, S. and Fan, V. 16, 40 Aster DM (healthcare group), 38 Asato, W. 98–99, 102 Atte, F. 1 Australia (as migration destination country), 2, 19–21, 26, 36, 38, 62–63, 80, 84–46, 97, 111, 137 Auxiliary Nurse Midwife, 39–40 Awang, N. 78 Bablu, J.S, 18 Babu, R. 41 Basu, R. 86 Bahrain, 36 BAME – Black Asian Minority Ethnic (in the UK), 119 Bangladesh, 4, 6 Bauer, T.K. and Zimmerman, K.F. 96 Belt and Road Initiative (China), 2, 9, 63–64, 159; see also one belt one road Betts, A. 157 bilateral agreement, 3, 8, 36, 42–44, 47, 63, 68, 97, 118, 126, 144, 151, 155, 159;

see also agreement and memorandum of understanding (MoU) bilateral relationship, 38 Blythe, J. and Baumann, A. 18 Bourgeault, et al. 2, 89, 118 brain drain, 1, 8, 52, 96, 116–71; brain waste, 96, 116–17, 122, 161, 163; see also care drain BRICS (Brazil, Russia, India, China and South Africa – nursing platform), 9, 64, 67 British Raj, 26 Buchan, J. 63 Buchan, J. and Catton, H. 1, 117, 126 Buchan, J. and Sochalski, J.A. 61 Buchan, et al. 74, 87 Cabanda, E. 97 Calabrese, J. 36 Campbell, J. 5, 7 campus recruitment (of nurse candidates), 21 Canada (as a migration destination countries), 2, 19–21, 36, 38, 54, 58, 64, 80–81, 88–89, 96–97, 109, 111, 119, 137, 150 Cangiano et al. 137 care deficit, 5; see also care crisis care drain, 2; see also brain drain care work 10–11, 83, 95–96, 98–99, 100–03, 105–11, 138–39, 142–47, 151, 157–59, 162; care work in Japan 98, 108, 110–11; care work training 95, 98, 100–03, 105, 117, 136; care work labour market, 141–42; licensure examination (for care work), 77–78, 85, 88, 95, 97–98, 144–46, 150, 155–56; pathways (to care work), 77, 98, 100–02; care work as sacred task

Index (in Japan), 143; as women’s work, 5, 118, 121, 124, 143 career choices (for nurses), 9, 24, 29, 74, 126, 144, 162; career (professional) development, 9–10, 24, 27, 29, 61, 150, 156, 160; career pathways, 9, 16, 21–22; civil service exam (for nurses), 22–24, 29 Carlos, R. 3, 9, 73–75, 109, 144 Carlos, R. and Adhikari, R. 147, 150 Carlos, R. and Sato, C. 74 Carlos, R, and Suzuki, Y. 100, 136, 147, 150–51, 159 Certified Care Workers – CCW (in Japan), 11, 135–36, 139, 142–46, 152 Chandna, H. 46 Cheap labour (nursing student as free labour) 18; migrant worker (cheap labour), 99 Chennai, 17, 24, 32 China 2, 4–6, 9, 53; Chinese government 53; Chinese Nursing Association, 59–60, 63–64, 67–68; China Scholarship Council 65; healthy China 2030, 57; nursing faculties, 62; nursing workforce labour market in China, 53, 55–56, 59, 68; one child policy (in China), 53; as a source country (of nurse migration), 55, 61–62; retirement age, 56; (nurses) working abroad, 61–63 Christian missionaries, 16, 41 Choi, S. and Lyons, L. 1 Chow-Bing, N. 3 Chua, G.P. 77–78 Clendon J. and Walker L. 56 Code of Conduct (in nursing), 40, 47 CGFNS – Commission on Graduate Foreign Nursing School and exam centre, 63 Connell, J. 2–4, 6, 41 Consulate General of India (in Dubai), 41, 44 contract-based nursing positions, 30 convenient sampling, 30 Cortez, G. 119 cosmetic surgery, 6 Covid-19 (pandemic), 9, 10, 16, 30, 41, 46, 65–67, 115–20, 158; (Covid-19 pandemic related) death of healthcare workers, 158; (Covid-19 pandemic and) national security, 121–22; impact (of the Covid-19 pandemic), 158–59, 162–63; (gendered) response to the

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pandemic, 115, 121, 123; (Covid-19) vaccine diplomacy (in the Philippines), 120, 126 Cornelisses, L. 119 Crawley, H. and Hagen-Zanker, J. 75 Creighton-Campbell, J. and Ikegami, N. 137, 139 cross-border mobility, 155, 157, 159, 164; see also international migration Delehanty, W. and Steele, B.J. 116, 120, 122–23 demographic time bomb, 135–36 demography (population), 4, 5, 162, 163 deskilling (of foreign educated nurses), 10, 95–96, 103–05, 109–11, 119, 146; deskilling (definition), 95–96, 110–11; see also downward professional mobility Dicicco-Bloom, B. 2 Dimaya et al. 2, 3, 4 downward professional mobility, 95–6, 104–09, 107, 118, see also deskilling Dubai, 25, 37–38, 41–44 Duffield et al. 56, Economic Partnership Agreement (EPA), 3, 7, 10, 98–100, 102–04, 107–8, 110–11, 136, 138, 144–46, 150, 154, 159; EPA candidates, 109–10, 138, 147; minimum standard (to be an EPA candidate), 99, 103 Ehrenreich, B. and Russell-Hochschild, A. 2, 137 Elbe, S. 2 employment preference, 19, 28–29, 30–13, 97, 152; employment opportunities, 9, 15, 19, 21, 23, 27–28, 73, 104, 125 emigration check (required) registration (ECR), 27, 42, 45, 47; e-migration (in India) 42–43 emerging economies (emerging superpower), 6 Encinas-Franco, J. 118, 123–24 ethical recruitment, 2, 38, 61, 118, 126, 161, 163–64 European Bank for Reconstruction and Development, 63 family reunification (reason for migration), 82, 85, 109 Fang, Z. 61–63, 159

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fangcang (specialist mobile hospital for Covid-19 cases in China), 66, 67 Federation of (Indian) Chamber of Commerce and Industry, 42, 49 feminisation of migration, 2, 5, 89 focus group discussion, 17, 20–22, 24, 76, 138 Foreign Technical Trainee (in Japan), 102, 136, 146–47, 152, 159 Gaur, S. 42 Garner et al. 3, 4, 27 gender, 5–6; gendered migration, 2, 5; gendered nationalism, 115–21, 127 General Nurse Midwife (GNM), 39 Germany 63, 97, 118, 126, (bilateral agreement with) George, S. 2, 12, 31 Giddens, A. 120 Gill, R. 40 global circulation of care (care chain), 2, 96 global health challenges (of noncommunicable diseases), 55–56; see also non-communicable diseases global (health) governance, 7, 14, 157, 160, 163–64 global nursing shortage, 1, 4, 5, 9, 11, 16, 18, 55–56, 62, 65–67, 79, 88, 119, 125, 156; see also health workforce shortage Graham et al. 56 Green, D. 5 Goh, Y. and Lopez, V. 74, 87, 89 Golden residency (visa for healthcare workers in UAE), 46 Gokulan, D. 41 Gotehus, A. 95–6 government (nursing) colleges (in India), 17, 19, 20–24, 29–30, 32; government jobs (in India), 21–23, 25, 29–30, 42, 104; government hospitals, 22–9, 88, 104; Government of India, 42–45 Gulf Co-operation Countries (GCC), 3, 8, 19, 25, 27, 38, 41, 159 Guevarra, R. 97 health workforce shortage (and mal distribution) 1, 57–58; see also nursing shortage healthcare labour market, 1, 2, 4–7, 53, 56, 97, 137, 141, 151; privatisation and market expansion (in healthcare), 4, 6, 18, 38

Hearly, M. 16 Henley, G. 5 Hirano, et al. 3, 101, 109, 135–37, 147, 159 Hochschild, A.R. 96 Hu, et al, 3, Hudspeth, R. 56 human rights, 2, 31, 157; right to health, 2; labour rights. 47, 118, 163–64; violation of human rights (of migrant workers), 31 Humphries, et al. 74–5 immigration policy, 7, 63, 88, 137, 144, 146, 150, 157 India, as a (global) nurse supplier, 2, 4, 7, 16, 19, 31, 36–38, 41, 45–47; nurse shortage (in India), 1, 7, 16, 18–19, 30, 37; as a trading partner, 37 Indian diaspora (in UAE), 36, 37 Indian nurse migration, 7–8, 16–17, 24–25, 27–28, 31, 37–39, 43, 45–47, 156, 158 Indian Nursing Council, 17, 18, 30, 39–40, 45 Indonesia, 3, 4, 32, 78, 98, 136, 144 International Council of Nurses, 61, 64–65, 158, 161, 163 International recruitment (of nurses and healthcare professionals), 1–2, 7, 9, 11, 21, 24, 27, 31, 38, 43, 47, 61, 63–65, 73, 77, 88, 118, 137, 141, 144, 149–51, 155–61, 163–64 International English Language Testing System (IELTS), 21, 95 International Organisation on Migration, 95 Interviews, 17–19, 21, 76, 103, 138 Ireland (as migration destination), 19–21, 26, 75 Irudaya, R. 16–17, 26, 31 Irudaya, R. et al. 26, 31 Invisible and underemployed (nurses), 96, 119–20, 126 Israel (as migration destination), 97 Japan, 3–5, 9, 11, 95–105, 108, 111, 135–36; Japan’s Gold Plan, 140; Japanese language, 88, 100–01, 110, 146; long-term settlement policy (for foreign workers in Japan) 88, 97–98; Nursing Association (of Japan) 98, 135, 136, 139; see also EPA

Index job security, 23–24, 30–31, 125; job preferences 28, 31, 97, 100 Johari, A. 30 Joint working group (on skill development of Indian workers), 43 Johnson, et al. 16 Kajimoto, T. 158 Karnataka, 8, 38–9 Karan, et al. 1, 36–37 Kelly, D. 162, Kerala 8, 17, 20, 22–24, 30, 32, 36–41, 45–46, 48 Khadria, B. 18, 36, 38, 45 Khadria, B. and Tokas, S. 41 Kingma, M. 1, 31, 55, 62, 68, 74, 155, 156, 159, 160,162 Komazawa, O. 16 Korzeniewska, L. and Erdal, M.B. 96 Kurup, D. 30 Kuwait (as migration destination), 32, 36 Lan, P.C. 5 language barrier, 62, 107 110 Letvak et al. 56 Lewis, S.J. 58 life expectancy, 5, 56, 140 Li, J. and Lambert, V.A. 58 Lien Foundation (Singapore), 76–79, 81, 85 Liu, et al. 4, 56 long-term care facilities and long-term care insurance, 137 Lu, et al. 58, 60 Mackintosh et al. 156, 163 Malay Peninsula, Malaysia, 25–27 Marcus et al. 3, 4 Masui, et al. 139, 148 marriage (as a reason for migration), 27 Matsuno, A. 3, 4, 74, 79 Masselink, L. and Lee, S.D. 97, 118 McCurry, J. 5, 135 medical tourism, 2, 6, 16, 38, 48, 77, 78, 159–160 memorandum of understandings (MoUs), 42–45, 64, 126, 159; see also bilateral agreements Michel, S. and Peng, I. 5, 6 Migration aspiration (of nurses), 74, 84, 86–87; (migration) barriers 10, 156; cap (or ban) on migration 10, 115–24, 155; circular migration, 38, 64; decision making (for migration) 75–80;

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destination, 16, 19, 25, 27, 38, 41, 74–79; family integration (reason for migration), 84; geographical proximity 83; long-term settlement 74–5; market-led migration, 100; migration pathways 8, 75–76, 100–01, 110–11; reasons for migration, 21, 26–27, 84; salaries (as reason for migration), 80, 119; social network, 75 migration diplomacy, 125 migration dream, 115; dream interrupted 121, see also migration aspiration migration governance, 7, 11, 45, 118, 155, 157, 161, 163–4 migration trap, 96, 118–19, 125, 160 migrant rights, 163 minimum wage, 30, 42 MSc (nursing), 39 multi-step migration, 38; 73–9, 109, see also stepwise migration Mutual Recognition Agreement, 159; mutual recognition of curriculum, 45 Muramatsu, N. and Akiyama, H. 5, 135–36, 139 Nair, S. 16, 18, 41 Nair, S. and Irudaya, R. 18 Nakata, Y. and Miyazaki, S. 59 National Health Policy (of India), 18 National Skill Development Corporation, 42 Naufal, et al. 37 Navallo, K. 10, 162 Nepal 3, 6, 64–65, 160 New Delhi, 41–43 non-communicable disease (NCD), 4, 7, 53, 56, see also global health challenges nurse education, 7, 31; nursing curricula 40; professional development 40; education institutions 18; enrolled nurse, 75–6; employment option 22; lucrative business (nursing education in India) 18; nursing education (as a “passport” to migration), 41; professional autonomy 60; professional regulation and standard (of nursing), 18; tuition fees/costs 19, 40; social status (of nurses) 21; professional license (abroad) 62; registered nurse, 75–76; nursing aids 76 nurse migration, 2, 6, 9–10, 24, 26–27, 31, 39, 62–63, 96–98, 104, 111, 117–18, 125, 127, 155, 157, 159, 163;

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age bar, 40; job opportunities (in nurse receiving countries), 6–7; nurse supplying/ exporting countries, 6, 16, 77, 117; see also migration destinations ‘Nursing Now’ (a global campaign), 161 nursing workforce shortage, 1, 53–54; (nursing) wastage and turnover, 9, 58–60 non-nursing jobs, 110 nursing (workforce), 17, 37, 53–58, 61, 65–68, 116, 126, 155, 161–63; nurse recruitment 97, 99, 118; (nurse) retention, 61, 74, 79, 83, 85–87, 138, 142–46, 150, 157, 162 Noree, et al. 6 Oda, H. 8, Oda et al. 25, 29, 31 OECD – Organisation for Economic Cooperation and Development, 16, 36, 80 Oh, Y.A. 118 Ohno, S. 98, 144 Ogawa, R. 98–99, 136, 144–45 one belt one road, 67; see also Belt and Road Initiative opportunity for women, 16; opportunity trap (of migration), 97 Ortiga, Y. 96–97, 118–19 Osella, C. and Osella, F. 38 Oulton, J. and Hickey, B. 19 Pakistan, 4, 54 Pande, A. 118, 123 Parrenas, R. 96, 118 Paul, A.M. 74, 109 Percot, M. 3, 8, 38 Percot, M. and Iruday, R. 17 Peterson, V. 115–16 Pittman, P. et al. 62 PrisoNurses, 124–26 private nursing college (in India), 18, 23, 40; private college graduates, 27–28; private hospital (in India), 24–25, 27, 31 Plotnikova, E. 2, 11 population demography, 4, 5 162–63 PPE – personal protective equipment (shortage), 115 Pratt, G. 96, 109 privatisation of healthcare, 7, 18, 39 professional hierarchy (in nursing), 76, 108

quality inspection, 19 Rao et al. 19 recruitment agencies, 31, 41, 45; Boss Job 77, 97 Reddy, S.K. 16 Redfoot, D.L. and Houser, A.N. 17, 19, remittance, 46, 108–89, 117, 123, 125–26 return migration (from overseas), 27–26, 64 Rolfe, H. 162 Runnels, V. Packer, C. and Labonté, R. 2 salary (as reason for migration), 26–27, 117; in Japan, 109; in Singapore, 86; in the Philippines, 117-,19 Salami, et al. 96 Salaverria, L. 125 Santos, A. 115 Sassen, S. 2 Saudi Arabia (as migration destination), 25, 36, 41 Sharma, J.R. 5, 40 Sheikh, et al. 3 Singapore, 2, 6, 9, 19, 25, 73–6, 83–85, 87; Singapore (as an attractive) Asian migration destination, 88; job satisfaction (in Singapore), 86–87; Singapore (nursing) licensing exam 85; Singapore Nursing Board 76; stepping stone (for international migration), 79 snowball sampling, 17, 30, 75–76, 103 skill erosion, 96 stepwise migration, 9, 38, 73–75, see also multi-step migration stigma (of being a nurse), 16 Song, J. 136–39, 144 South Korea, 6 specified skills work visa (for Japan), 136 Spentz, et al. 18 study abroad, 55 Sun, et al. 58, 60, 66 Suri, N. and Kumar, M. 43 Survey, 17, 19 Switzerland, 20–21 Tamil Nadu (India), 17, 19–20, 24, 26, 29–32, 39; Tamil communities (abroad), 26 Tangcharoensathien, et al. 3, 4, technical trainee student visa (for Japan), 136, 146, 152, 159 technology assisted care, 11, 148–49 Thailand, 1, 2, 6, 9, 64, 160

Index the Philippines, (as nurse supplying country) 3, 9–10, 77, 97–99, 109–11, 117–18, 128, 133, 144, 155; Philippine educated nurses 9, 10, 16, 73–77, 95; Philippine Overseas Employment Agency (POEA), 73, 99, 115, 119, 122–23, 125; Philippine Nursing Association, 99, 114, 126; Filipino nurse emigration, 10, 97, 115, 117–18; Philippine economy, 6, 117, 123–24, 133; state-assisted migration (in the Philippine), 118; Filipino Nurses United 125; see also migration ban/ cap Timmons, et al. 16, 27 transnationalisation of care, 96 Tsujita, Y. 8 Tsujita, Y. and Komazawa, O. 16 Thomas, P. 25, 31 Thompson M. and Walton-Roberts, M. 3 Thiruvananthapuram, 17, 32 trafficking (of human), 43–44, 118 UAE – United Arab Emirates, 7–8, 25, 36–39, 41–74, 73, as migration destination, 25, 36, 38, 41, 73 United Kingdom (as a migration destination), 19–21, 26, 36, 56, 64, 67, 97, 117–18, 120, 133 United States (as migration destination) 19–21, 23, 36, 56, 80, 117 Universal Health Coverage, 7, 161, 163 valuing care work, 162 Varghese, V.J. 41, 45 Vietnam (as source country of care workers), 3, 6, 98, 136, 144

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Walton-Roberts, M. 3. 8, 25, 32, 40–41 Walton-Roberts et al. 25, 31, 40, 45 Wang, H.L. 64 Wong, L. 78 WHO – World Health Organisation 6, 55; WHO Assembly, 47 WHO Code of Practice (on the international recruitment of healthcare workers), 2, 38, 47, 157, 161 Wickramasekara, P. 42–43 William, et al. 65 Winklemann‐Gleed, A. 2 Wongboonsin, et al. 6 workforce (nursing, care, and health workforce) distribution disparities 36, 55, 57–8, 60, 156, 158, 164; (as nursing, care, and health workforce) planning and management challenges 4, 7–8, 11, 73, 75, 151; (nursing, care, and health workforce) shortage, 1, 3–5, 7, 11, 16, 53, 55–56, 58–61, 65, 67, 88, 135–37, 141–42, 144–45, 148–49, 151, 156–58 working conditions (as of poor conditions), 40, 117 Xiao, et al. 53, 59 Xu, L. 59, 61–62 Xu, Y. and Zhang, J. 61–62 Ye, et al. 58, 60 Yeates, N. 2, 96 Yeates, N. and Pillinger, J. 2, 3, 4 Zhou, et al. 61–62 Zhu, J. 3–5, 55–62 Zhu, et al. 54–61, 66