The COVID-19 pandemic has highlighted the imperative for universal health coverage (UHC) in protecting public health, promoting inclusion, and building the resilience of our communities in the face of a health crisis. For health systems to deliver UHC, they require an adequate, trained, well-equipped and motivated health workforce. Even before the pandemic, the world was already short of health care workers, and the crisis has only made this problem more acute. To meet the surge in demand for health care, governments have embarked on various measures to bring in migrant health workers, as well as refugees with a health background who are already present in the country. Measures include facilitating renewal of work authorisation, international recruitment, allowing temporary licensure, granting of limited permits and fast-tracking the processing of recognition of foreign qualifications. Many migrant and refugee workers have stepped up to the call by governments. At present, they make up a significant proportion of health workers at the frontlines.
This article will look at the issue of health worker migration as it intersects with the challenges of health labour migration governance and the struggle for universal health care, particularly in light of the current pandemic.
In the 86 countries surveyed by the World Health Organization (WHO) as part of the State of the World’s Nursing Report, it is estimated that 1 out of every 8, or 3.7 million, nurses are foreign-born or foreign-trained. Breaking this down further, migrants make up 12 percent of the 1.9 million health workers in the UK, 17 percent of the 12.4 million health workers in the US, and 11 percent of the total health workforce in the European Union. It is also worth noting that more than 80% of the global health workforce are women.
Since the beginning of the outbreak of COVID-19 in early 2020, health workers at the frontlines are the ones who face the highest risk of exposure to and infection from the virus. The lack of necessary personal protective equipment (PPEs), inadequate facilities and staff shortages have led to high levels of infections and deaths among health workers. Globally, health workers account for 1 out of 6 cases of infections reported to the WHO. In early September, Amnesty International reported over 7,000 health worker deaths since the start of the pandemic. Among those who died are migrant health workers, including a high number of those working in elderly care homes. In the USA, almost half of the nurse deaths due to COVID-19 are nurses of colour or those with a migrant background. A third of the deaths are nurses from the Philippines, a country that is known to deploy thousands of health workers overseas. In the UK, COVID-19 infections in the nursing workforce were highest among the Asian ethnic group. The risk of dying from the virus was reported to be higher in black, Asian and minority ethnic (BAME) communities. Like in the US, a disproportionate number of those who have died are Filipino health and care workers. This tragic and massive loss of health workers’ lives and the high number of migrants amongst those lost are not, however, merely a correlation.
The pandemic has exposed the systemic problems and the fragile state of our health systems. Over the years, as a result of the adoption of neoliberal economic policies in many developed and developing countries, public health services have been constantly underfunded. Years of austerity and contraction of public health budgets have left public services under-resourced and understaffed. The decades of privatisation and marketisation of our health services have led to inefficiencies, corruption, job cuts, overburdening of staff, and the rising cost of health coverage. For many health workers, staying in the health workforce has become unbearable that many have left the profession, and for others, migrating to higher income countries became the only choice.
While facing a shortage of health workers, developing countries are also losing their health workers to migration. Over the last decade, the number of migrant doctors and nurses working in OECD countries has increased by 60%, and the rate is even higher for those migrating from developing countries that already have severe health workforce shortages. While high income countries benefit from the international recruitment of trained health workers, poor countries are being deprived of their skilled health workers after having invested their limited resources in their training. Faced with a depleted health workforce and weak public health services, the ability of developing countries to address their population’s health needs and to battle pandemics and other disasters is compromised, thereby making the goal of UHC impossible to achieve. This pattern of poor countries training and then losing their health workers to rich countries could, in some ways, be seen as a perverse albeit unintended subsidization by poor countries of the health systems of rich countries. The consistent underfunding of systems in the Global North has been enabled by increasingly drawing on skilled migrant labour, paying lower salaries, with worse working conditions and less legal recourse. This process adversely affects health systems globally, permitting underfunding and causing understaffing.
Amid this pandemic, health workers across the world are taking to the streets demanding for their rights and safety at work, including access to personal protective equipment (PPEs) and adequate facilities, for just compensation, for social protection, for their inclusion in decision-making, and funding of public health services. During lockdown, many cities saw their inhabitants applauding health workers from their homes as a sign of recognition. As much as applause makes noise, noise is not enough. What health workers need is the proper recognition of their value in society. They do not want to be called heroes who are expected to risk their lives in the line of duty. They are professionals dedicated to their job of caring for patients and saving lives.
Migrant health and care workers at the frontlines demand the same. Due to their migration status, particularly those on temporary permits, and the need to send remittances back home to support their families, migrant health and care workers endure long working hours, poor wages, few benefits, and are reluctant to raise their concerns for fear of sanctions that range from discrimination to deportation. Women, who make up the majority of these workers, are doubly vulnerable as they endure precarious working conditions while expected to carry out care responsibilities within family and society. The pandemic has pushed these migrants beyond an already unsustainable point, thus public funding for health systems will have to be cognizant of their vulnerabilities as migrants to avoid the continued exploitation of their status.
The COVID-19 pandemic has highlighted the vital role of public health services in promoting UHC in battling the crisis. It has also shed light on the systemic problems leading to the current fragile state of our health systems, their impacts on the health workforce, including the loss of health workers due to migration, disproportionately affecting developing countries. The situation of migrant health workers at the frontlines needs particular attention. Countries, rich and poor, are facing the pandemic, albeit not on equal footing. Public health systems require an adequate and healthy workforce to provide UHC. Recruitment of migrant workers to meet the surge in demand for health care has been considered as one of the solutions. However, dependence on health labour migration is problematic as it ignores the systemic inequalities that should have been addressed in the first place. A rights-based approach, taking into account issues of human rights, gender dimension, fair economic policies and shared governance responsibilities, is a necessary first step to the governance of health labour migration, therefore balancing the rights of workers, the right to UHC and fair outcomes for both origin and destination countries.
Public Services International, the global federation of public service trade unions representing almost 10 million health and social care workers organized by its affiliated unions in the health and social care sectors, have been engaged on the issue of health workforce migration for over a decade. PSI works with its unions in organising health workers, including migrant health workers, promoting social dialogue and lobbying for rights-based migration policy at global, regional and national levels. Grounded on its experience, PSI puts forward the following recommendations in addressing the nexus of UHC and health labour migration governance, particularly considering the pandemic crisis. 
Genevieve Gencianos is the Migration Programme Coordinator of Public Services International, the global trade union federation of public service workers. Email: genevieve.gencianos(at)world-psi.org
 The recommendations elaborate on the 5-point-plan outlined in Pillinger and Yeates (2020), “Building Resilience Across Borders: A Policy Brief on Health Worker Migration,” published by Public Services International and Friedrich-Ebert-Stiftung.