Migration of Nursing and Midwifery Workforce from Kerala Study Findings

Tomas Zapata HRH Regional Advisor WHO-SEAR Outline

• Production of nurse and midwives

• Stock of nurse and midwives

• Migration of nurse and midwives from Kerala

• Conclusions & recommendations Production Number of training institutions in Kerala (2005-2016) 250 219 204 200 General Nursing and Midwifery 150 126 133 BSc (Nursing) 91 100 Auxiliary Nursing and Midwifery 50 12 20 20 0 15 Total in 2016: 287 2005 2012 2016 - 11% public – 89% Source: Indian Nursing Council/KNMC private Production Production capacity (number of seats, maximum production capacity) 8000 • Number of college seats 6000 in 2016: 17,600 4000 (91% private) 2000 • Growth in seats faster 0 in public ANM GNM BSc MSc PB BSc PB colleges (Nursing) (Nursing) (Nursing) Diploma seen from Source: Indian Nursing Council2012 2013 2014 2015 2016 2012-16 (marginal) Source: Indian Nursing Council Production Production capacity (number of seats, maximum production capacity) 8000 • Number of college seats 6000 in 2016: 17,600 4000 (91% private) 2000 • Growth in seats faster 0 in public ANM GNM BSc MSc PB BSc PB colleges (Nursing) (Nursing) (Nursing) Diploma seen from Source: Indian Nursing Council2012 2013 2014 2015 2016 2012-16 (marginal) Source: Indian Nursing Council Production Number of nurse registrations with KNMC (2009-2016) 6000

5000

4000 General Nursing and Midwifery 3000 BSc (Nursing)

2000 Auxiliary Nursing and Midwifery 1000

0 New registrations of 2009 2010 2011 2012 2013 2014 2015 2016 nurses and midwives Source: Kerala Nurses and Midwives Council in 2016: 9,766 Stock of Nurses & Midwives

Bihar Himachal Pradesh Assam Jharkhand Allopathic Doctors Nurses and Midwives Orissa All Rajasthan Tripura Arunachal Pradesh Madhya Pradesh West Bengal Meghalaya Goa Uttar Pradesh Manipur Andhra Pradesh Sikkim India Jammu & Kashmir Karnataka Chattisgarh Nagaland Lakshadweep Tamil Nadu Punjab Mizoram Uttarakhand Andaman & Nicobar Islands Gujarat Maharashtra Haryana Delhi Kerala

0 5 10 15 20 25 30 Density per 10000 population

Source: Rao, KD, Shahrawat, R., & Bhatnagar, A. (2016). Estimates based on 2012 NSSO Stock of Nurses & Midwives

Bihar Himachal Pradesh Assam Jharkhand Allopathic Doctors Nurses and Midwives Orissa All Rajasthan Tripura Arunachal Pradesh Madhya Pradesh West Bengal Meghalaya nurses Goa India: 3.1 Uttar Pradesh Manipur and midwives /10,000 Andhra Pradesh Sikkim (NSSO 2012) India Jammu & Kashmir Karnataka Chattisgarh Nagaland Lakshadweep Tamil Nadu Punjab Mizoram Uttarakhand Andaman & Nicobar Islands Gujarat Maharashtra 3.1 Haryana Delhi Kerala

0 5 10 15 20 25 30 Density per 10000 population

Source: Rao, KD, Shahrawat, R., & Bhatnagar, A. (2016). Estimates based on 2012 NSSO Stock of Nurses & Midwives

0 5 10 15 20 25 30 Density per 10000 population Kerala Source: Rao, KD, Shahrawat, R., & Bhatnagar, A. (2016). Estimates based on 2012 NSSO Stock of Nurses & Midwives

0 5 10 15 20 25 30 Density per 10000 population Kerala Source: Rao, KD, Shahrawat, R., & Bhatnagar, A. (2016). Estimates based on 2012 NSSO Stock of Nurses & Midwives Number of vacancies of nurses working in rural health facilities in Kerala (2016)

In Required Sanctioned Vacant Shortfall Position Year position [R] [S] [S–P] [R–P] [P]

Health workers 2007 6 003 5 670 5 634 36 369 (female)/ANMs at 2012b 5 384 4 232 4 173 59 1 211 subcentres and PHCs 2016 5 399 7 929 7 950 * * 2007 909 830 740 90 169 Health assistants 2012 NA NA NA NA NA (female)/LHVs at PHCs 2016 824 13 13 0 811 2007 1 658 2 811 3 064 * * Nursing staff at PHCs 2012 2 328 2 099 2 014 85 314 and CHCs 2016 2 399 3 610 3 969 * *

Source: Bulletin on Rural Health Statistics 2016, MoHFW Stock of Nurses & Midwives Number of vacancies of nurses working in rural health facilities in Kerala (2016)

In Required Sanctioned Vacant Shortfall Position Year position [R] [S] [S–P] [R–P] [P]

Source: Bulletin on Rural Health Statistics 2016, MoHFW Number of vacancies of nurses working in rural health facilities in Kerala (2016)

In Required Sanctioned Vacant Shortfall Position Year position [R] [S] [S–P] [R–P] [P]

Health workers 2007 6 003 5 670 5 634 36 369 (female)/ANMs at 2012b 5 384 4 232 4 173 59 1 211 subcentres and PHCs 2016 5 399 7 929 7 950 * * 2007 909 830 740 90 169 Health assistantsVacancies in private sector??? 2012 NA NA NA NA NA (female)/LHVs at PHCs 2016 824 13 13 0 811 2007 1 658 2 811 3 064 * * Nursing staff at PHCs 2012 2 328 2 099 2 014 85 314 and CHCs 2016 2 399 3 610 3 969 * *

Source: Bulletin on Rural Health Statistics 2016, MoHFW Overseas migration from Kerala

80,000

70,000

60,000

50,000 Stock of Nurses and 40,000 Nurse Assistants Nurse and Nurse 30,000 Assistant Migrants 20,000

10,000

0 2011 2013 2016

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram Overseas migration from Kerala

80,000

70,000

60,000

50,000 Stock of Nurses and 40,000 Nurse Assistants Nurse and Nurse 30,000 Assistant Migrants 20,000 31%

10,000

0 2011 2013 2016

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram Overseas migration from Kerala

80,000 Emigration rate: 32.8% (2011) 70,000 23.2% (2016) 60,000

50,000 Stock of Nurses and 40,000 Nurse Assistants Nurse and Nurse 30,000 Assistant Migrants 20,000 31%

10,000

0 2011 2013 2016

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram Percentage share of emigrant nurses and nurse assistants in major destination countries

Source: Kerala Migration Survey 2016, Center for Development Studies Migration within India from Kerala

Madhya Pradesh Andhra Pradesh 1% Chhattisgarh 1% Gujarat 1% Rajasthan Others* 1% 1% 1% West Bengal Uttar Pradesh 2% 6% Karnataka 41% Tamil Nadu 14%

Delhi 31%

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram Trends in migration of nurses from Kerala to other Indian States 1500 4000

3000 1000

2000

500 1000

0 0 2012 2013 2014 2015 2016 Total Delhi Nursing Council Karnataka Nursing Council Tamil Nadu Nursing Council Uttar Pradesh Nursing Council

Source: Data on issuance of certificates of no objection, Kerala Nurses and Midwives Council Conclusions & Recommendations • Slowing down of overseas migration of nurses, high production capacity, low vacancy rates & low internal migration: moving towards an oversupply of nurses

• Reasons for declining migration of nurses from Kerala to foreign countries ought to be investigated further. Perceived low quality/skills?, soft skills, language? How to address them

• Oversupply contributes to low salaries in private sector + wage differential between Kerala and abroad could translate into demands for salary increases. Recent nurse strike in Kerala reflective of this - Ensuring enhanced working conditions, salaries, enforcement of minimum wage in private sector - Govt could create conditions for enhancing role of nurses in health system – e.g. licensing nurse practitioners, creating prescription formulary for nurses • Sign MoU between Kerala and destination countries, promote internal migration • Methods

Spare slides Migration from Kerala

Stock of Nurses and Nurse Nurse and Nurse Net Emigration Rate Year Assistants Assistant Migrants (%)* 2011 61,613 30,038 32.8% 2013 63,224 28,138 30.8% 2016 68,161 20,622 23.2% *Calculated as: [Migrant nurses and nurse assistants /(Resident nurses and nurse assistants + Migrant nurses and nurse assistants)] * 100

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram Migration from Kerala

Stock of Nurses and Nurse Nurse and Nurse Net Emigration Rate Year Assistants Assistant Migrants (%)* 2011 61,613 30,038 32.8% 2013 63,224 28,138 31% 30.8% 2016 68,161 20,622 23.2% *Calculated as: [Migrant nurses and nurse assistants /(Resident nurses and nurse assistants + Migrant nurses and nurse assistants)] * 100

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram Migration from Kerala

Stock of Nurses and Nurse Nurse and Nurse Net Emigration Rate Year Assistants Assistant Migrants (%)* 2011 61,613 30,038 32.8% 2013 63,224 28,138 30.8% 9.6% 2016 68,161 20,622 23.2% *Calculated as: [Migrant nurses and nurse assistants /(Resident nurses and nurse assistants + Migrant nurses and nurse assistants)] * 100

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram Migration from Kerala

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram

• Fall in net emigration rate of nurses and nursing assistants • Over 90% of emigrant nurses employed in private sector before migration • Nurses migrated for an average of 5-6.5 years Number of nurse registrations with KNMC (2009-2016)

6000 7210 Number of seats in 2013

5000

4000 General Nursing and Midwifery 3000 BSc (Nursing) 2152 2000 Auxiliary Nursing and Midwifery 1000

0 2009 2010 2011 2012 2013 2014 2015 2016

Source: Kerala Nurses and Midwives Council Number of nurse registrations with KNMC (2009-2016)

6000 7210 Number of seats in 2013

5000 70% gap 4000 General Nursing and Midwifery 3000 BSc (Nursing) 2152 2000 Auxiliary Nursing and Midwifery 1000

0 2009 2010 2011 2012 2013 2014 2015 2016

Source: Kerala Nurses and Midwives Council Percentage share of emigrant nurses and nurse assistants in major destination countries (2011, 2013, 2016)

40%

30%

22% 20% 15% 12% 10% 10% 6% 6% 6% 4% 3% 3% 3%

% Saudi UAE Kuwait UK USA Qatar** Canada Others Germany Maldives Australia Arabia* 2011 2013

Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram Factors influencing Migration Patterns

‘Push’ Factors ‘Pull’ Factors

• Low remuneration • Shortage of nursing personnel in destination countries • Difficult working conditions, including: • Ageing population - Low patient-nurse ratio, high workload • Higher salaries, personal and professional - Limited training and education opportunities opportunities • Unclear career pathways • Migration to other Indian states: Employment in major cities and leading hospital facilities (public/pvt) • Drop in migration from Kerala to Gulf countries due to recent structural changes in policies: - Nurses migrating to ECR (emigration checked required) countries require emigration clearance - Foreign employers to register with eMigrate system - Recruitment only via state-mandated agencies – ODEPC, NORKA-ROOTS, TNAI - Reduction of quality of trained nurses (English, soft skills)?? - Increased requirements in destination countries • Interviews with nursing students indicate preference for permanent, full-time position in Kerala public health system over migration (particularly to Gulf countries) Conclusions & Recommendations

• Sign MoU between Kerala and destination countries

• Estimates of production, stock, and migration foreground extent of divergence between data sources:

- Nodal institution in Kerala should track and compile information on migrant health workers, including nurses – NORKA-ROOTS undertaking steps on this

- Implement live register for nurses, interoperable with other info systems to provide strategic information (including migration data) Migration of Nurses from India

• Steady declines in annual inflow of Indian nurses to OECD countries since 2005 • US and UK see declining share of emigrant nurses, while Canada and Australia have registered rises (absolute numbers much smaller than Gulf) • Shifts in preference for destination countries may partly be result of destinations’ migration policies – more family-friendly policies, longer term residency prospects

5000

2500

0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Canada United Kingdom United States New Zealand Italy

Source: Health Workforce Migration – OECD