Migration and global justice: realistic options for here and now

Immigration is one area of concern for the author of Global Justice: a Cosmopolitan Account, which examines how several policy options might advance or undermine global justice. In this extract, some real and perceived consequences of immigration are explored, taking as a particular case study, health worker migration. There are a number of problems with current policy, but for the developing rather than the developed countries
Gillian Brock
23 May 2010

If all border controls were demolished, how many people would actually move? How many people really want to uproot from their familiar surroundings, friends, and family in order to face the sometimes uncertain prospects that await them in a new land? Though estimates vary,[i] there is interesting evidence to suggest that people would move in fairly limited numbers.[ii] For instance, quite a few countries had open border arrangements with former colonies in the past, which allowed open migration from the Caribbean between 1950 and 1980. In the period, only 0.6% of the Caribbean population moved to the US and England, though there were clear economic attractions for doing so. Citing evidence from Bob Sutcliffe, Teresa Hayter extrapolates that the figure today would be around 24 million per year, which amounts to growth of around 2.4% in the population of industrialized countries.[iii]

Clearly, it does not follow that people will exercise the option of emigrating if they have it. Most people do not like the idea of leaving everything they know. Yet, the North spends huge amounts to keep its borders closed. The cost in terms of financial expenditure, opportunities foregone, loss of human life, and human rights abuse is huge.[iv] European governments spent $4-8 billion per year on refugee control and assessment during the early 1990s, and Teresa Hayter calculates that the cost of detaining 800 people in British detention centers and prisons was around 48 million pounds per year, which is approximately twelve times what it would have cost if those people were on income support and enjoying a housing benefit.[v] Governments are willing to spend much more on making life difficult for refugees than those refugees would gain from welfare entitlements. However, some might think this is money well spent if it successfully deters others from coming.

Despite the enormous cost of trying to keep people out at borders, in a post 9/11 world it would be futile to argue for removing all border controls. People’s interests in security and a peaceful way of life now rule this out. So the relevant questions are ones about what restrictions on entry there should be, not whether there should be any restrictions at all, and in particular, about whether countries should be more generous in the quotas or permitted maxima for immigration.

Most countries have annual maxima for the number of immigrants they will admit. One option is that these should be raised, but there are other policies we should also entertain. Here are some:

1. Stay with the status quo: stay with current quotas and levels of immigration admitting current levels of potential citizens.

2. Increase the number of people who may be permitted as potential citizens.

3. Decrease the number of people who may be permitted as potential citizens.

4. Stay with the current status quo for admitting potential citizens, but permit more migrants for work purposes.

5. Consider the potential for “win-win” possibilities that benefit home and host countries, immigrants and locals.

Here we will consider the first three proposals in more detail.

The first three options - some considerations

Before looking at increasing, decreasing, or staying with the status quo with respect to quotas, we should examine the current situation. Is immigration generally a positive, negative, or neutral phenomenon for those affected? There are three important groups to be considered: the immigrants, those in the host countries (the countries to which the immigrants go), and those in the home countries (those they exit).

Starting with the benefits to the host countries, there is much agreement among economists that immigration increases the wealth of host countries.[vi] Though the overall economic effect may be very positive, some worry that the distribution of those gains is uneven. In particular, the concern is that some citizens bear heavy costs, such as loss of jobs, lowering of wages, or increased competition. Let us investigate these claims further.

Do immigrants take jobs away from local workers? In many cases, the jobs immigrant workers take up are perceived as dangerous, dirty, or demeaning ones that local workers (apparently) prefer not to do (not at prevailing wages, at any rate), such as picking fruit and cleaning. Some argue that, far from taking work away from others, immigrants actually create jobs for others. Because immigrants need housing, transportation, food, and so forth, the number of jobs expands[GB1] .[vii] Indeed, immigrants often start new businesses and thereby create jobs.[viii]

Do immigrants lower wages? There is some evidence to suggest that wages in certain sectors (such as agriculture, construction, and service industries, especially restaurants) are lowered by the arrival of many immigrants.[ix] Some unskilled workers do suffer from the additional competition, because the newcomers are typically willing to work for less. However, this may provide more incentives for citizens to acquire further skills and, thus, be positioned to fill better paying jobs. Immigration may therefore result in more investment in self-education, which leads to increased earning power. Even if immigration results in lower wages (at least for some), this is not necessarily a bad thing. The lower wages may cause firms to expand in a particular area, creating more jobs. Prices of consumer goods may also fall. Immigrants can also contribute to rising wages if they open up new markets and opportunities. For instance, as China becomes more willing to open borders for trade, those immigrants with Chinese heritage may be well situated to facilitate trade with China. So the Chinese-Canadian community may be an asset to Canada, for example, that not all other nations share. Opening up new markets may bring more opportunities to citizens than they would otherwise have enjoyed.

There are several other ways immigrants can benefit developed countries. Demographic changes are challenging the continued viability of the social security arrangements in many parts of the Western World.[x] For instance, in the US when the baby boom generation retires, about 20% of the population will be in retirement, whereas the figure has been roughly 13% for preceding generations. Moreover, since life expectancy over 65 has been increasing, those in retirement can expect to live longer than previous generations. An increasingly older population puts additional strain on funding for healthcare. As the birth rate has been declining, however, there will be fewer productive adults available to support the ageing retired population. In 1960 there were about 5 workers for every social security recipient, but when the baby boomers retire it is predicted there will be approximately 2.5 workers to support each social security recipient.[xi] Such a situation would inevitably mean either higher taxes or cuts in social security, unless more young adult workers are admitted.[xii]

Increasing the number of immigrants can help strengthen industry in the developed world, but is this an overall gain for promoting what I have identified as the goals of global justice? Restricting immigration may have the effect of compelling firms in the developed world to export certain kinds of jobs, such as in manufacturing, to developing countries, and this could provide much-needed employment opportunities to those countries aiming to develop.           

At any rate, we see that immigrants can provide benefits. Do they pose costs, such as increased welfare dependency and crime, environmental damage, or undesirable cultural change? I have found no evidence to suggest immigrants use welfare services or contribute more to crime in significantly greater proportions than the general population.[xiii] The more difficult accusation to rebut conclusively may be that immigrants pose cultural costs. One concern here is that immigrants threaten the nation to which they move by undermining the host culture or the sense of unity and solidarity citizens feel toward each other. Is this fear warranted? There are nations that would be hypocritical to make very much of this (assuming for the moment that it is true), namely, all the nations comprised largely of immigrants, notably the USA, Australia, Canada, and New Zealand. Nevertheless, concerns of this kind weighed heavily with many throughout the histories of those nations, leading to exclusionary policies that aimed to prevent immigration by people thought to be “unassimilatable”. These have included, for example, Poles, Greeks, Jews, and Italians. As we see over time, however, all nations are “works-in-progress”, and their characters change. The contribution of newer groups to this process is as likely to be positive as negative.

Whatever costs there might be in accepting immigrants, it seems there are many benefits to host countries in continuing to permit them entry. Indeed, countries would not continue to permit immigrants to enter in such high numbers if they were not, overall, benefiting the country.

I assume that immigrants, all things considered, perceive themselves to benefit from immigration, or they would not remain in the host country. Much more problematic is whether immigration benefits those who remain in the countries of origin. The evidence here suggests that permitting more immigrants to go to developed countries can have disastrous effects for the home country. In the next section I focus on the case study of emigration of health care workers, which provides a clear illustration of the harms that must frequently be suffered by those in source countries who do not emigrate.

Brain drain: the case of health care workers

“Brain drain” occurs when many skilled citizens from a particular country emigrate, thus draining the country of workers with high levels of training and leaving behind the less skilled (or unskilled). This phenomenon can have noticeable effects for the country they exit. Brain drain among health professionals is particularly widespread and damaging for developing countries. These countries typically have poor heath care resources in any case, so the loss of trained health care workers is felt even more greatly than it might be in places that are better resourced.

In some cases, the departure of health care workers from developing countries threatens the viability of the health care systems in those countries, especially in sub-Saharan Africa. Consider, for instance, how in Zambia, only 50 of the 600 doctors that have been trained in the country since independence have remained.[xiv] Furthermore,

… in Africa alone, where health needs and problems are greatest, around 23000 qualified academic professionals emigrate annually. Information from South African medical schools suggests that a third to a half of its graduates emigrate to the developed world. The loss of nurses has been even more extreme — for example, more than 150 000 Filippino nurses and 18000 Zimbabwean nurses work abroad. A recent report from the United Kingdom estimated that 31% of its doctors and 13% of its nurses are born overseas; in London the figures are 23% and 47% respectively. These reported figures are likely to be underestimates as many migrate unofficially.[xv]

The costs to developing countries of such losses are enormous.[xvi] Indeed, it is clear that in sub-Saharan Africa basic health care delivery is significantly threatened by this phenomenon.[xvii] In particular, the recruitment of foreign nurses by developed countries “has grown to such proportions that it is affecting the sustainability of entire health systems in some developing countries, depriving them of knowledge, skills and expertise – often at the expense of governments that have paid for the education of these nurses”.[xviii] In some cases, countries lose more nurses every year than they train, for instance, in 2001 Ghana lost 500 nurses, which is more than double the number of new nurses graduated in that year.[xix]

Recruiting health workers to rich countries can have varying effects on source countries, sometimes benefiting them through additional remittances, training, and experience. In some cases, such as the Philippines, the country trains more nurses than it needs in order to supply foreign markets. Those workers then remit funds back to their families, so these migrant workers are an important source of foreign revenue. But it is overwhelmingly the case for the vast majority of developing countries that the net effect is extremely negative.[xx] When rich countries recruit workers trained in poor countries without compensation, what is effectively happening is that poor countries are subsidising the health care of citizens of affluent countries, while losing significant resources in the process.[xxi]

On some accounts the lack of health care workers in developing countries such as those in sub-Saharan Africa, “is an emergency that demands urgent action. The impact of healthcare worker migration from developing to developed countries is a significant component in this crisis”.[xxii] Losses in sub-Saharan Africa are said to be so dramatic that, to some theorists “the haemorrhage of health professionals from African countries is easily the single most serious human resource problem facing health ministries today”.[xxiii] While, many countries have actual and projected shortages of health workers, the shortages in sub-Saharan Africa are greatest where one million health workers are needed to meet the Millennium Development Goals by 2015.[xxiv] For countries which already have severe shortages of health professionals (as measured by being below one health worker per 1000 population) further loss of workers is most likely to result in loss of health services and significant loss of health in the countries’ populations. Furthermore, billions of dollars of aid that is available to address global health problems, such as HIV/AIDS, are not being put to use because of the lack of health care professionals.[xxv]

Arguably, it is not the total number of health care professionals that exist in the world at large that is a problem, but rather their distribution. Consider how, for instance, while only 21% of the world’s population resides in Europe and North America, they command 45% of the world’s doctors and 61% of its nurses. Africa, which contains 13% of the world population, has only 3% of its doctors and 5% of its nurses. 1.3% of the world’s health care workers provide services to 13.8% of the world’s population in a region suffering 25% of the world’s disease burden. It is estimated that 2.5 health workers per 1000 of population is needed for basic health care delivery.[xxvi] Europe enjoys 10.3 per thousand, while Africa on average has 1.4 per thousand.[xxvii]

Why do so many health workers want to leave? Medical professionals cite reasons such as poor remuneration, bad working conditions, lack of professional development or promotional opportunities, lack of security, and lack of funding as important factors in their decision to leave. Developed countries often offer better pay and working conditions, or career and training opportunities not available in developing countries.

Furthermore, there are the recruitment practices of health care organizations in the developed world, which encourage and facilitate migration of health care workers. These practices can vary, but often include fairly active practices such as aggressively targeting the entire workforce of a particular hospital or region within a country already facing critical shortages via recruitment agents (thus stripping entire communities of their health care personnel),[xxviii] or targeting the entire graduating class of a particular university.[xxix] Some recruitment agencies have not followed basic principles for contracting in good faith and have given misinformation about the job, conditions, or pay, or have misled workers into accepting jobs that are incompatible with their skills and experience.[xxx] When I talk about recruitment practices here I will bracket such concerns entirely. I argue that, even if agreements following basic rules of fair contracting are struck between an individual healthcare worker and a healthcare organization, significant issues of justice remain.

What has been done about the problems identified? The main response so far has been to establish codes of practice for the international recruitment of healthcare professionals. I have discussed these codes in detail elsewhere.[xxxi] One of the most significant of these was that drawn up by the Department of Health of the United Kingdom in 2001 and revised in 2004. It is supposed to guide all recruitment into the National Health Service. The UK code is a good example. It begins with the claim that international recruitment is a legitimate strategy in developing an adequate healthcare workforce, and that there are benefits that accrue to the individuals recruited, such as advanced training. The principle offered as doing much of the justificatory work is that healthcare professionals may be targeted for recruitment only from developing countries for which there are government-to-government agreements with the United Kingdom that explicitly permit recruitment activities. However, if individuals from those countries volunteer themselves by personal application (rather than through a recruitment agency) they may be considered for employment.

The code of practice is also supplemented with a document outlining the best practice benchmarks for international recruitment. Here again we see the same point emphasized. “There is no active recruitment of healthcare professionals from those developing countries that are included on the Department of Health website”, these being ones falling outside of the relevant agreements.[xxxii] However in discussion of that principle it is allowed that healthcare organizations may consider unsolicited applications from any individual who lives in a developing country provided the application is made not using a recruitment agency. Another key benchmark identified is that international recruitment should be “sensitive to local healthcare needs so that international recruitment from any country should not destabilize local health care provisions”.[xxxiii] But taking this benchmark seriously would mean that recruitment from many countries (whether by personal application or not) will simply have to be prohibited if some of the facts cited earlier are taken seriously, especially those concerning the crisis in healthcare in sub-Saharan Africa.

Noticeably absent from the UK code is any talk of compensation when individuals are recruited from developing countries. Compensation to the country of origin seems appropriate because there are a number of costs that a departing individual imposes on the society she leaves, especially when her training was subsidized by that society. Such costs include the expense of training, loss of service and health to the home country, and loss of revenue from taxed wages.[xxxiv]

Compensatory measures could take a number of forms, including technological, technical, or financial assistance, the setting up of training programs, or instituting (and helping to enforce) compulsory service before departure is permitted. The latter is a particularly attractive option as it provides a good fit between the loss or disadvantage that the source country must bear and how the departing individual may be able to remedy this. Where there is such a compulsory service requirement, developed countries should assist developing countries enforce it, for instance by not issuing visas to those who have yet to perform the necessary service.[xxxv]

So far, the codes have failed in numerous ways to solve the problem. First, the current codes are all voluntary. Recent research suggests that there are widespread violations of the UK code.[xxxvi] While having a voluntary code in place is a first step that can be taken, it is not a sufficient response. Governments could do more than they are currently doing. Indeed, given that governments are the ones who supply visas to the potential recruits, it seems they have an excellent opportunity to do much more. However, what would really address the root of the problem more effectively is each country’s achieving self-sufficiency with respect to health care resources. For developing countries, especially in sub-Saharan Africa, this means training more health care professionals. More needs to be invested in health care professionals. Where are the additional resources to come from? Some might come from compensation for health care professionals poached from the developing world, but there are many other neglected sources. Helping developing countries themselves collect more of the revenue they are actually owed would be a major contribution.

A comprehensive solution to the problems I have been discussing requires at least the following components: (1) an international code that specifies uniform standards for both private and public sectors, and that applies to all countries in similar circumstances; (2) an international agency that oversees activities, brokers compensation, can punish violators (perhaps by levying meaningful fines), and so forth; (3) each country’s aiming at and achieving self-sufficiency with respect to human resources in health care; and perhaps (4) addressing the seemingly insatiable demand for health care in developed countries. I note that there is already at least one version of an international code that could do the job outlined in (1) and several proposals concerning (2).[xxxvii]

Would we be interfering unjustly with individuals’ relevant freedoms, such as the freedom of movement or occupational freedom by, say, denying visas to potential immigrants who were trained in countries with dire healthcare resources? I do not necessarily think so. The rights to emigrate that healthcare workers have must be balanced against the responsibilities they have to the countries in which they were trained. Perhaps if we denied them visas unconditionally we would be interfering inappropriately. However, if we allow visas to be granted on condition that the emigrant or healthcare organization that would employ them offers adequate compensation to the country of origin, this strategy strikes a reasonable balance, in my view.[xxxviii]  (So to be clear: I am not against movement across borders per se, but rather specifically against uncompensated movement across borders, where compensation is clearly warranted.  The idea is that by better regulating movement across borders we can appropriately manage compensation developing countries are owed in a way that does not necessarily restrict important freedoms.)

As this case study of health care workers and brain drain has shown, there are tremendous costs that can accrue to the country of origin from increased immigration. Better management of the flow of immigrants may reduce these, but as things currently stand, the health care costs of departing health care workers are enormous and considerably worsen the health care resources available to those left behind. There are other serious disadvantages for those in the home country, especially those that affect their livelihoods. 

Decreasing the numbers of immigrants permitted to enter developed countries may then have a number of good consequences for less developed countries; for instance, as we have just seen, it would help them retain skilled workers, and thereby retain resources crucial for helping to improve prospects for better lives in struggling countries. I also observed that if immigration is more restricted than it currently is, so that fewer workers who will work for lower wages are available, more firms from developed countries might relocate to the developing world where wages are much lower. This could provide better job prospects for those in the developing countries than would have been possible if more of them were permitted to travel to other countries.[xxxix]

Have I neglected an enormous source of revenue that immigrants (and migrants) provide for developing countries, by remitting money back to their countries of origin? Are there not significant advantages to developing countries in allowing their citizens to work overseas, when this provides much more revenue than if they remained at home? I discuss the advantages and disadvantages of remittances next, in discussing the fourth option, which is whether to increase migrant labour.



This article is a slightly modified extract from Gillian Brock Global Justice: A Cosmopolitan Account (Oxford: Oxford University Press, 2009). It is published with permission from Oxford University Press which is gratefully acknowledged. 

For the ensuing discussion on proposals four and five, see Chapter 8, Global Justice: a Cosmopolitan Account. 


 United Nations Population Division estimates World Migrant Stock for 2005 at 190 633 564. The chart put out by the UN Population Division in October, 2006 uses the 2005 figures, and can be accessed at:http://www.un.org/esa/population/publications/2006Migration_Chart/2006IttMig_chart.htm. According to Castles and Miller, the United Nations estimated that in 2002 there were 185 million migrants. It is not clear how many of these were immigrants. Presumably,far less. For more estimates see S. Castles and M. J. Miller The Age of Migration, 3rd edition, (Basingstoke: Palgrave, 2003), p. 4.

 Teresa Hayter Open Borders: The Case against Immigration Controls (London: Pluto Press, 2000), p. 153.

 Ibid., p. 153. Bob Sutcliffe, Nacido en otra parte: Un ensayo sobre la migracion international, el desarollo y la equidad (Bilbao: Hegoa, 1998).

 It is estimated that between 1993 - 2000, 2063 people died trying to enter Europe. See http://www.united.non-profit.nl/pages/List.htm

 Hayter, Open Borders, p. 163.

 See Julian Simon, The Economic Consequences of Immigration (Basil Blackwell, 1989), Appendix C; Mark Kleinman “The Economic Impact of Labour Migration” in Sarah Spencer (ed.) The Politics of Migration: Managing Opportunity, Conflict and Change (Malden, MA: Blackwell, 2003), pp. 59-74; also Open Letter to US President and Congress, 19 June 2006, with more than 500 signatories (mostly academics), including 5 Nobel Laureates:http://www.independent.org/newsroom/article.asp?id=1727

and accompanying press release:


 Peter Stalker The No-Nonsense Guide to International Migration (London:Verso, 2001), pp. 64-65. Those US cities with a higher proportion of immigrants do not have higher rates of unemployment, according to research by Stephen Moore cited in “Making and Remaking America” by Philip Martin and Peter Duignan, Hoover Essays, HE25, www.hoover.org, ISBN 0-8179-4462-1, p. 35. For similar results in Europe, see Stalker, The No-Nonsense Guide to International Migration, p. 78 also Castles and Miller, The Age of Migration, p. 194.

 Seglow, “The Ethics of Immigration”, p. 326; also Nigel Harris Thinking the Unthinkable: The Immigration Myth Exposed (London: I. B. Tauris, 2002), pp. 57-60.

 George Borjas, “Immigration and Welfare: A Review of the Evidence” in The Debate in the United States over Immigration, eds. Peter Duignan and Lewis Gann (Stanford: Hoover Institution Press, 1998), pp. 121-44.

 Steven Camarota “Immigration in an Aging Society: Workers, Birth Rates, and Social Security”, Center for Immigration Studies, Backgrounder, April 2005, available at: http://www.cis.org/articles/2005/back505.html; and Ronald Lee and Timothy Miller “Immigration, Social Security, and Broader Fiscal Impacts” AEA Papers and Proceedings: New Issues in Immigration 90/2 (2000): 350-354.

 Annual Report of the Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds (2007), p. 48, accessible at this site: http://www.ssa.gov/OACT/TR/TR07/.

 Some dispute that the US needs large numbers of immigrants for this purpose; for instance, Roy Howard Beck, The Case Against Immigration: The Moral, Economic, Social, and Environmental Reasons for Reducing U.S. Immigration back to Traditional Levels (New York: W.W. Norton, 1996). Indeed, it is not easy to find arguments that increased immigration will substantially help with this problem. Lee and Miller “Immigration, Social Security, and Broader Fiscal Impacts” acknowledge that increased immigration would have a positive affect on Social Security, but not a large one. For arguments that immigration would not help the social security problem (in the US, EU, and Japan), see Hans Fehr, Sabine Jokisch, Laurence Kotlikoff, “The role of immigration in dealing with the developed world’s demographic transition,” Finanzarchiv, 60:3 (2004), 296-324. A version is available at:

 See for instance, Stalker, The No-Nonsense guide to International Migration, p. 82. See also Harris, Thinking the Unthinkable, for claims that this issue is a ‘red herring’ contrary to popular prejudices.

 P. Bundred, and C. Levitt “Medical Migration: who are the real losers?” Lancet 356 (2000): 245-246.

 Tikki Pang, Mary Ann Lansang, and Andy Haines “Brain drain and health professionals: A global problem needs global solutions,” British Medical Journal, 324 (2002): 499-500, pp. 499-500. We see similar figures for the US. Nearly 25% of America’s physicians are trained outside America, and almost two thirds of them come from low and lower-middle income countries. 14% of recently licensed nurses are trained abroad. See, for instance, Amy Hagopian, Matthew J Thompson, Meredith Fordyce, Karin E Johnson and L Gary Hart, “The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain,” Human Resources for Health 2 no. 17 (2004); also Linda Aiken, James Buchan, Julie Sochaliski, Barbara Nichols and Mary Powell, “Trends in International Nurse Migration,” Health Affairs 23 no.3 (2004).

 Pang, Lansang, and Haines, “Brain drain and health professionals”, p. 500.

 J. Huddart and O. Picazo, The health sector human resource crisis in Africa (Washington DC: Bureau for Africa, Office of Sustainable Development, United States Agency for International Development), 2003; and A. Ehman and P. Sullivan “South Africa appeals to Canada to stop recruiting its MDs” Canadian Medical Association Journal 164 (2001): 387-388.

 See “Position Statement on Recruitment and Rights of Foreign Nurses”, p. 1, available at www.aft.org, April, 2006.


 See, for instance, “Position Statement on Recruitment and Rights of Foreign Nurses”, p. 2.

 For instance, when the Canadian province of Alberta recently recruited 44 South African physicians, whose combined training costs were $11.6 million, in effect some of the world’s poorest were subsiding some of the world’s richest with respect to health care. The exodus from South Africa has been particularly troubling. Indeed, lost training costs in South Africa exceed the combined estimated education assistance received by South Africa in 2000 for all purposes, not merely for health professional training. “The ethics of overseas recruitment for Global Health”, p. 4, available at http://www.ukglobalhealth.org/Default.aspx?textID=141&cSectionID=6.

 See “The healthcare skills drain – a call to action”, a report by the British Medical Association available at http://www.bma.org.uk/ap.nsf/Content/skillsdrain p. 1, 4th of May, 2006.

 “The ethics of overseas recruitment for Global Health, p. 3, available at http://www.ukglobalhealth.org/Default.aspx?textID=141&cSectionID=6

They refer especially to the work of D. Sanders, D. Dovlo, W. Meeus, U. Lehmann “Public Health in Africa” in R. Beaglehole (ed.), Global Public Health: A New Era (Oxford: Oxford University Press, 2003), pp. 135-55.

 The goals set targets for reducing poverty, disease, hunger, illiteracy, environmental degradation, and discrimination against women.

 “The healthcare skills drain – a call to action”, p. 1.

 “Teething Problems in Africa’s healthcare” in The African Executive available at http://www.africanexecutive.com/modules/magazine/articles.php?article=699&magazine=71.

 Also, the World Health Organization has a target for the doctor to population ratio of 1 per 1000. In the 25 poorest countries, the doctor patient ratio is only 1 per 25000. Currently the doctor patient ratio is 1 per 500 in wealthy countries “The ethics of overseas recruitment for Global Health”, p. 3.

 James Buchan and Delanyo Dovlo “International Recruitment of Health Workers to the UK: A Report for DFID” available from the DFID Health Systems Resource Centre, at www.healthsystemsrc.org; “Position Statement on Recruitment and Rights of Foreign Nurses”.

 See Norm Daniels, Just Health: Meeting Health Needs Fairly (New York: Cambridge University Press, 2008), Chapter 13; Susan Maybud and Christiane Wiskow, “`Care trade’: The international brokering of health care professionals,” in Christine Kuptsch (ed.) Merchants of Labour, ILO publications (2006): 223-238, available from the International Labour Organization website at:


 Ibid., also “Position Statement on Recruitment and Rights of Foreign Nurses”.

 “Health in Developing Countries and Our Global Responsibilities” in Angus Dawson (ed.) The Philosophy of Public Health (Aldershot: Ashgate, forthcoming).

 “Code of Practice for the international recruitment of healthcare professionals” p. 10, available at http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyandGuidance/PublicationsPolicyandGuidanceArticle/fs/en?CONTENT_ID=4097730&chk=D1/b1A


 We do see talk of compensation in other codes.  See Brock, “Health in Developing Countries and Our Global Responsibilities”.

 Recently a code was adopted that, in theory at least, has global scope. This is the code titled “Ethical Restrictions on International Recruitment of Health Professionals from Low-Income Countries” which was adopted at the World Federation of Public Health Associations. Available at www.apha.org/private/2005_proposed_policies/D3_2005.pdf. International agencies, such as the WHO, the World Medical Association, and UNESCO could all play a role in trying to achieve respect for an international code.

 Between March 2001 and 2002, twice the number of nurses were registered in the United Kingdom from South Africa as the year before in which there were no ethical recruitment guidelines.  See “The ethics of overseas recruitment for Global Health”, p. 4, available at: http://www.ukglobalhealth.org/Default.aspx?textID=141&cSectionID=6.

 Some plausible codes include: “Commonwealth Code of Practice for the International Recruitment of Health Workers”, p. 2, available at: http://www.spnf.org.au/bulletin/codeofpractice.html. Also, “Ethical Restrictions on International Recruitment of Health Professionals from Low-Income Countries”. It is plausible that the WHO could perform the job specified in (2), though this could also be done in conjunction with the International Organization for Migration, and/or the United Nations Development Program and/or the World Medical Association and/or the Council of International Organizations of Medical Societies. For more on implementing policies governing compensation see, for instance, “Migration of Health Personnel”, WHO document WPR/ICP/ECP/7.2/001/ECP(1)2005.4 4 February 2005.

 In the first instance, it would be the departing individuals who would be responsible for paying compensation. But I assume that in many cases, probably the vast majority, making individuals solely responsible would effectively undermine their freedom of movement so significantly, given their inability to pay compensation of the order of magnitude required. It is not unfair if the health care organizations that are employing emigrants and thereby deriving significant benefits from them should be made to absorb the costs. This proposal balances concern for individuals and the countries they depart more appropriately than other alternatives.

 Thomas Morrison “The Relationship of U.S. Aid, Trade, and Investment to Migration Pressures in Major Sending Countries”, International Migration Review 16/1 (982): 4-26; and Robert Carbaugh “Is International Trade a Substitute for Migration?” Global Economy Journal 7/3 (2007): 1-13. There is also considerable potential for relocating service provision or “services offshoring” to less developed countries, as we have seen in the last decade, especially in India. See Rafiq Dossani and Martin Kenney “The New Wave of Globalization: Relocating Service Provision to India” World Development 35/5 (2007): 772-791.




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