Linking Migration, Food Security and Development

the Southern aFrican Migration prograMMe

Linking Migration, Food Security and deveLopMent

Migration poLicy SerieS no. 60 Linking Migration, Food Security and deveLopMent

Jonathan cruSh

SerieS editor: proF. Jonathan cruSh

Southern aFrican Migration prograMMe (SaMp) 2012 acknowLedgeMentS SAMP wishes to thank the IDRC and OSISA for their financial support. This report is a joint publication with the African Food Security Urban Network (AFSUN) and also appears in the AFSUN Urban Food Security Series as No. 9. The AFSUN research reported here was funded by CIDA under the UPCD Tier One Program. The author wishes to thank Bruce Frayne, Wade Pendleton and Cassandra Eberhardt for their assistance.

Published by the Southern African Research Centre, Queen’s University, Canada

First published 2012 Production by Bronwen Müller, Cape Town

Printed by Megadigital, Cape Town contentS page executive SuMMary 1 introduction 6 internaL Migration and urban Food Security 8 urbanization and circuLation 8 Food Security and Stretched houSehoLdS 14

South-South Migration and Food Security 17 changing Migration StreaMS 17 croSS-border Migration and urban Food Security 26

MigrantS and Food Security 28

Migration and Food tranSFerS 34 concLuSion 41 endnoteS 43

Migration poLicy SerieS 49

LiSt oF tabLeS tabLe 1: Southern aFrican urban popuLation, 1950-2050 8 tabLe 2: Southern aFrican urbaniSation, 1950-2050 10 tabLe 3: South aFrican MunicipaLitieS experiencing greateSt 10 in-Migration, 2001-6 tabLe 4: proportion oF Migrant and non-Migrant houSehoLdS 14 tabLe 5: occupationS oF Labour MigrantS in South aFrica, 2006 21 tabLe 6: reFugee appLicationS in South aFrica by country oF 24 origin, 1994-2004 tabLe 7: reFugee appLicationS and deciSionS in South aFrica, 2009 25 tabLe 8: SourceS oF incoMe oF Migrant houSehoLdS 26 tabLe 9: MonthLy expenSeS oF Migrant-Sending houSehoLdS 27 tabLe 10: SourceS oF houSehoLd incoMe 30 tabLe 11: houSehoLd dietary diverSity 33 tabLe 12: Food tranSFerS by city 38 tabLe 13: Frequency oF tranSFerS by area oF origin 39 (%, paSt 12 MonthS) tabLe 14: typeS oF Food tranSFerred 40 tabLe 15: typeS oF tranSFer aS houSehoLd Migrant-StatuS 41

LiSt oF FigureS

Figure 1: Southern aFrican urban popuLation, 1950-2050 9

Figure 2: internaL Migration in zaMbia, 1996-2006 12

Figure 3: LegaL entrieS to South aFrica FroM reSt oF aFrica, 1990-2010 18

Figure 4: LegaL entrieS FroM ziMbabwe to South aFrica, 1980-2010 19

Figure 5: MaLe eMpLoyMent in South aFrican MineS and FeMaLe 20 eMpLoyMent in LeSotho garMent FactorieS, 1990-2006

Figure 6: deportationS FroM South aFrica, 1990-2008 22

Figure 7: SourceS oF houSehoLd incoMe 31

Figure 8: incoMe terciLeS 31

Figure 9: Food Security oF Migrant and non-Migrant houSehoLdS 32

Figure 10: SourceS oF Food For Migrant and non-Migrant houSehoLdS 34

Figure 11: totaL Food tranSFerS to urban houSehoLdS 36

Figure 12: Frequency oF Food tranSFerS to urban houSehoLdS by area 37 oF origin

Figure 13: Frequency oF Food tranSFerS to urban houSehoLdS by area 39 oF origin (% oF houSehoLdS) MMIGRATIONigration PpOLICYoLicy SERIESerieS NnOo. 4560

eExecutiveXECUTIVE SSuUMMARYMMary

woealth issues workers have recently are one risenof the to categories the top of of the skilled international profession- developmentals most affected agenda: by (a)globalization. Food Security; Over and the (b) past Migration decade, andthere Development. has emerged Each a substantial has its own body global of research agency champions,that tracks internationalpatterns of internationalgatherings, national migration line of ministries health personnel, and body of THresearch. Global and regional discussions about the relationship between assesses causes and consequences, and debates policy responses at global migrationand national and scales. development Within coverthis literature, a broad range the case of policy of South issues Africa including is remittanceattracting growing flows, the interest. brain drain, For almost the role 15 ofyears diasporas South andAfrica return has migrabeen - tion.the target Strikingly of a ‘globalabsent raiding’from these of skilleddiscussions professionals is any systematic by several discus devel-- sionoped of countries. the relationship How to between deal with population the consequences migration of and the food resultant security. out- Ifflow the of global health migration professionals and development is a core policy debate issue sidelines for the nationalfood security, gov- theernment. current international food security agenda has a similar disregard for migration.This paper The aims primary to to focus examine of the policy agenda debates is food and insecurity issues concerning and under- nutritionthe migration and how of skilled enhanced health agricultural professionals production from the by country small farmers and to can resolvefurnish thesenew insights endemic on problems. the recruitment There is patterns a tendency of skilled to ignore health the per-real- itysonnel. that migrationThe objectives is a critical of the foodpaper security are twofold: strategy for rural households up andQ down +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H the African continent. If migration is a neglected aspect of discussionsment ofabout skilled rural professionals food insecurity, from it South is almost Africa totally in the absent health from considerationssector. ofThe the paper causes draws and uponimpact a detailedof food securityanalysis amongstof recruitment urban populations.advertising In practice, appearing therefore, in the there South is aAfrican massive Medical institutional Journal and for substantivethe disconnectperiod 2000-2004 between and these a series two developmentof interviews agendas.conducted with Currentprivate conceptualisations recruiting enterprises. of the food security crisis in Africa provide an inadequateQ 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< basis for working at the interface between migration and food security.key stakeholders First, there inis thethe assumptionSouth African that health food security sector, theis primar paper- ily a ruraloffers problem a series that of willrecommendations be resolved through for addressing technical the innovation problem of amongstskilled smallholders health (inmigration. the guise These of a newrecommendations Green Revolution). are grounded What seems toin be both forgotten South in African this romantic experience view and of the an interrogationAfrican rural houseof inter-- hold is thatnational its food debates security and is ‘good not simply, policy’ or practice even mainly, for regulating a function recruit- of what it doesment. or does not produce itself. Up and down the continent rural householdsThe paper purchase is organized some intoor most five of sections. their food Section and they Two do positions so with cashdebates that about they thereceive migration from household of skilled membershealth professionals who have migrated within a to earnwider income literature in otherthat discussesplaces within the international the country and mobility across of borders. talent. The evidenceSection Three for Southern reviews Africaresearch is thaton the these global rural circulation households of do health not invest pro- remittancesfessionals, focusing in agriculture in particular but in uponbasic necessities,debates relating including to the food experience purchase.of countries Rural infood the security, developing in other world. words, Section may Fourbe improved moves the but focus will notfrom beinternational resolved by tocurrent South approaches African issues to food and insecurity.provides new empirical mate- rialA drawn second from assumption the survey is thatof recruitment food security patterns in urban and areas key interviewsis about pro- motingundertaken urban with agriculture. health sector The obsessionrecruiters withoperating urban in agriculture South Africa. may be well-intentionedSection Five addresses but it derivesthe questions from misplaced of changing idea policy that increasedinterventions food in productionSouth Africa is thetowards key tothe urban outflow food of security. skilled healthThe primary professionals determinant and the of foodrecruitment insecurity of inforeign African health cities professionals is not production to work shortfalls in South but Africa. the lack The of access to food and that means the absence of a regular and reliable income with which to purchase it. 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EXECUTIVE SUMMARY city, access varies considerably from household to household with wage employment, other income generating activity, the size and structure of ealth workers are one of the categories of skilled profession- the household, the educational level of the household members, access to als most affected by globalization. Over the past decade, social grants and being embedded in social networks. there has emerged a substantial body of research that tracks There are some recent signs of recognition of the reality that migra- patterns of international migration of health personnel, tion and remittances play an important role in the food security strategies H of rural households. A recent issue of the journal Food Policy, for exam- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is ple, suggests that “the sending of a migrant means the loss or reduced attracting growing interest. For almost 15 years South Africa has been presence of one or more members of the household. On the consump- the target of a ‘global raiding’ of skilled professionals by several devel- tion side this clearly means fewer mouths to feed and to support in other oped countries. How to deal with the consequences of the resultant out- ways. On the production side, migration means the loss of labor and, in flow of health professionals is a core policy issue for the national gov- fact, the negative consequences of migration on nutrition are likely to ernment. come through this labor loss.” The major positive impact of migration This paper aims to to examine policy debates and issues concerning is the remittances sent home by the migrant which can have direct and the migration of skilled health professionals from the country and to indirect effects on production and consumption. This is an important furnish new insights on the recruitment patterns of skilled health per- issue, but so is the relationship between migration and the food security sonnel. The objectives of the paper are twofold: of the urban household. Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Food security needs to be “mainstreamed” into the migration and ment of skilled professionals from South Africa in the health development agenda and migration needs to be “mainstreamed” into sector. The paper draws upon a detailed analysis of recruitment the food security agenda. Without such an effort, both agendas will pro- advertising appearing in the South African Medical Journal for ceed in ignorance of the other to the detriment of both. The result will the period 2000-2004 and a series of interviews conducted with be a singular failure to understand, and manage, the crucial reciprocal private recruiting enterprises. relationship between migration and food security. This report sets out to Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< promote a conversation between the food security and migration agen- key stakeholders in the South African health sector, the paper das in the African context in the light of what we know and what we offers a series of recommendations for addressing the problem of need to know about their connections. This report focuses primarily on skilled health migration. These recommendations are grounded the connections in an urban context. Four main issues are singled out in both South African experience and an interrogation of inter- for attention: (a) the relationship between internal migration and urban national debates and ‘good policy’ practice for regulating recruit- food security; (b) the relationship between international migration and ment. urban food security; (c) the difference in food security between migrant The paper is organized into five sections. Section Two positions and non-migrant urban households; and (d) the role of rural-urban food debates about the migration of skilled health professionals within a transfers in urban food security. wider literature that discusses the international mobility of talent. The simplest way to examine the relationship between cross-border Section Three reviews research on the global circulation of health pro- migration and food security is to ascertain (a) how international migrants fessionals, focusing in particular upon debates relating to the experience address their own food and nutrition needs in the destination country of countries in the developing world. Section Four moves the focus from and (b) what happens to the income that they earn while away from international to South African issues and provides new empirical mate- home. The two questions are related to one another for the amount of rial drawn from the survey of recruitment patterns and key interviews money available to send home is to some degree contingent on the food- undertaken with health sector recruiters operating in South Africa. related expenditures of the migrant in the destination country. Migrants Section Five addresses the questions of changing policy interventions in rarely live alone and their income may often have to support members of South Africa towards the outflow of skilled health professionals and the “makeshift” households (not all of whose members can find work) as well recruitment of foreign health professionals to work in South Africa. The as second households. Migration within and to the Southern African region has changed

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EXECUTIVEdramaticallySUMMARY in recent decades. All of the evidence suggests that the region is undergoing a rapid urban transition through internal migration and natural ealthpopulation workers increase. are one There of the has categories also been of significantskilled profession- growth in temporaryals cross-border most affected movement by globalization. within the Over region. the pastThe decade,implications of the thereregion’s has new emerged mobility a substantial regime for bodyfood ofsecurity research in generalthat tracks (and urban food securitypatterns inof particular)international need migration much further of health exploration personnel, and Hanalysis. assesses causes and consequences, and debates policy responses at global andSAMP national has scales. conducted Within major this household literature, surveysthe case in of several South SADC Africa is countriesattracting which growing provide interest. valuable For almost information 15 years on South food expenditures Africa has been inthe migrant-sending target of a ‘global households. raiding’ of The skilled 2005 professionals Migration and by severalRemittances devel- Surveyoped countries. (MARS) Howinterviewed to deal 4,276with the households consequences with internationalof the resultant out- migrants.flow of health Cash professionalsremittances wereis a core the mostpolicy important issue for thesource national of income gov- inernment. all countries with 74% of all migrant-sending households receiving remittancesThis paper (with aims as to many to examine as 95% inpolicy Lesotho debates and and 83% issues in Zimbabwe). concerning In-countrythe migration wage of employmentskilled health was professionals a source of from income the for country 40% ofand house to - holdsfurnish followed new insights by remittances on the recruitment in kind (37%). patterns Remittances of skilled in-kind health areper- particularlysonnel. The important objectives in of Zimbabwe the paper andare twofold:Mozambique. At the other end of theQ spectrum, +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H only 8% of households receive income from the sale of agriculturalment produce of skilled and professionals only 5% receive from socialSouth grants. Africa in the health The sector.vast majority The paper of households draws upon (93%) a detailed purchase analysis food ofand recruitment groceries with theiradvertising income. Noappearing other expenditure in the South category African comes Medical close Journal although for a significantthe period minority 2000-2004 of households and a payseries for of cooking interviews fuel, conducted transportation, with clothing,private utilities, recruiting education enterprises. and medical expenses. A mere 15% spend incomeQ 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H

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EXECUTIVE SUMMARY brought or sent. In the case of Mozambique, 60% of households received food and in Zimbabwe, 45%. ealth workers are one of the categories of skilled profession- The next question is whether migrants are more food insecure than als most affected by globalization. Over the past decade, longer term residents of the poorer areas of Southern African cities. there has emerged a substantial body of research that tracks AFSUN conducted a survey in 11 SADC countries in 9 countries in patterns of international migration of health personnel, 2008 which helps to answer this question. Because access to income is H a critical determinant of food security in urban areas, it is important to assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is know if non-migrant households are more or less likely to access regular attracting growing interest. For almost 15 years South Africa has been and reliable sources of income, both formal and informal. Across the the target of a ‘global raiding’ of skilled professionals by several devel- sample as a whole, unemployment rates were high with nearly half of oped countries. How to deal with the consequences of the resultant out- both migrant and non-migrant households receiving no income from flow of health professionals is a core policy issue for the national gov- regular wage work. This suggests that migrants do not find it harder to ernment. obtain wage employment than permanent residents in the city. Migrant This paper aims to to examine policy debates and issues concerning households do find it easier to derive income from casual work while the migration of skilled health professionals from the country and to non-migrant households were more involved in running informal and for- furnish new insights on the recruitment patterns of skilled health per- mal businesses (20% versus 14%). Very few households in either category sonnel. The objectives of the paper are twofold: earn any income from the sale of home-grown agricultural produce. Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H The similarities in the access of migrant and non-migrant households ment of skilled professionals from South Africa in the health to the labour market and to various income-generating activities suggests sector. The paper draws upon a detailed analysis of recruitment that they might have similar income levels and, in turn, levels of food advertising appearing in the South African Medical Journal for security. In fact, there was one distinct difference in the income profile the period 2000-2004 and a series of interviews conducted with of migrant and non-migrant households. About a third of the households private recruiting enterprises. in each group fell into the lowest income tercile. However, 36% of non- Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< migrant households were in the upper income tercile, compared to only key stakeholders in the South African health sector, the paper 29% of migrant households. The situation was reversed with the middle offers a series of recommendations for addressing the problem of income tercile. In other words, migrant status is not a completely reliable skilled health migration. These recommendations are grounded predictor of whether a household will be income poor. However, non- in both South African experience and an interrogation of inter- migrant households are likely to have a better chance of having better national debates and ‘good policy’ practice for regulating recruit- incomes, primarily because some are able to access better-paying jobs. ment. The Household Food Insecurity Scale (HFIAS) measures household The paper is organized into five sections. Section Two positions access to food on a 0 (most secure) to 27 (most insecure) point scale. debates about the migration of skilled health professionals within a In terms of the relationship between the HFIAS and migration, migrant wider literature that discusses the international mobility of talent. households had a mean score of 10.5 and non-migrant households a Section Three reviews research on the global circulation of health pro- score of 8.9. This suggests that non-migrant households have a better fessionals, focusing in particular upon debates relating to the experience chance of being food secure than migrant households. The Household of countries in the developing world. Section Four moves the focus from Food Insecurity Access Prevalence (HFIAP) Indicator. found that only international to South African issues and provides new empirical mate- 16% of migrant households were “food secure” compared with 26% of rial drawn from the survey of recruitment patterns and key interviews non-migrant households. Although levels of food insecurity are disturb- undertaken with health sector recruiters operating in South Africa. ingly high for both types of household, migrant households stand a great- Section Five addresses the questions of changing policy interventions in er chance of being food insecure. South Africa towards the outflow of skilled health professionals and the Another question is whether there are any differences between recruitment of foreign health professionals to work in South Africa. The migrant and non-migrant households in where they obtain their food in the city. Migrant households were more likely than non-migrant house-

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EXECUTIVEholdsS toUMMARY patronise supermarkets. The opposite was true with regard to the informal food economy. This may have to do with the fact that non- migrant householdsealth workers would are be onemore of familiar the categories with alternative of skilled foodprofession- sources compared withals mostrecent affected in-migrants, by globalization. in particular, Over who the would past bedecade, more likely to knowthere about has andemerged recognise a substantial supermarket body outlets. of research A second that tracks difference is the extentpatterns to of which international households migration rely on otherof health households personnel, for food, Heither through sharing meals or food transfers. This was more common assesses causes and consequences, and debates policy responses at global amongand national migrant scales. than Withinnon-migrant this literature, households, the suggesting case of South the existenceAfrica is of strongerattracting social growing networks interest. amongst For almost migrants. 15 years Thirdly, South non-migrant Africa has house been- holdsthe target were ofmore a ‘global likely raiding’to grown of some skilled of professionalstheir own food by thanseveral migrant devel- households.oped countries. How to deal with the consequences of the resultant out- flowThe of healthmajority professionals of poor households is a core in policy Southern issue Africanfor the nationalcities either gov- consisternment. entirely of migrants or a mix of migrants and non-migrants. Rapid urbanization,This paper increased aims to to circulation examine policyand growing debates cross-border and issues concerningmigration havethe migration all meant of that skilled the numberhealth professionals of migrants andfrom migrant the country households and to in thefurnish city newhas growninsights exponentially. on the recruitment This is likelypatterns to continueof skilled for health several per- moresonnel. decades The objectives as urbanization of the continues.paper are twofold: We cannot simply assume that all poorQ +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=Hurban households are alike. While levels of food insecurity are unacceptablyment highof skilled amongst professionals all of them, from migrant South households Africa in the do healthhave a greater chancesector. Theof being paper food draws insecure upon witha detailed all of analysisits attendant of recruitment health and nutritionaladvertising problems. appearing This fact in needs the Southto be recognisedAfrican Medical by policy-makers Journal for and actedthe upon. period 2000-2004 and a series of interviews conducted with private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruitment. The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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EXECUTIVE SUMMARY introduction ealth workers are one of the categories of skilled profession- ver the last decade, two issues have risen to the top of the als most affected by globalization. Over the past decade, international development agenda: (a) Food Security; and there has emerged a substantial body of research that tracks (b) Migration and Development. Each has its own interna- patterns of international migration of health personnel, tional agency champions (the FAO and the IOM), its own H Ointernational gatherings (the Global Forum on International Migration assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is and the World Forum on Food Security), its own national line ministries attracting growing interest. For almost 15 years South Africa has been (Departments of Immigration and Home Affairs and Departments of the target of a ‘global raiding’ of skilled professionals by several devel- Agriculture and Food Security) and its own voluminous body of research oped countries. How to deal with the consequences of the resultant out- and scholarly publications. Some international organizations (such as flow of health professionals is a core policy issue for the national gov- the World Bank) deal with both issues but in such separate silos that ernment. they might as well be in separate organizations. There is, in other words, This paper aims to to examine policy debates and issues concerning a massive institutional and substantive disconnect between these two the migration of skilled health professionals from the country and to development agendas. The reasons are hard to understand since the con- furnish new insights on the recruitment patterns of skilled health per- nections between migration and food security seem obvious. Indeed, one sonnel. The objectives of the paper are twofold: cannot be properly understood and addressed independently of the other. Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Global and regional discussions about the relationship between migra- ment of skilled professionals from South Africa in the health tion and development cover a broad range of policy issues including sector. The paper draws upon a detailed analysis of recruitment remittance flows, the brain drain, the role of diasporas and return migra- 1 advertising appearing in the South African Medical Journal for tion. Strikingly absent from these discussions is any systematic discus- the period 2000-2004 and a series of interviews conducted with sion of the relationship between population migration and food security. private recruiting enterprises. There are a number of possible reasons for this. First, discussions of the Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< impact of migration on development tend to be pitched at the global key stakeholders in the South African health sector, the paper and national scale and focus on economic growth and productive invest- offers a series of recommendations for addressing the problem of ment. Secondly, when discussion turns to the household level, the debate skilled health migration. These recommendations are grounded focuses largely on remittance flows and the use of remittances by the in both South African experience and an interrogation of inter- household. There is a general consensus that the expenditure of remit- national debates and ‘good policy’ practice for regulating recruit- tances on basic livelihood needs is somehow non-developmental in that 2 ment. it does not lead to investment and sustainable productive activity. Not The paper is organized into five sections. Section Two positions only is this an extremely narrow perspective, it also means that the food debates about the migration of skilled health professionals within a needs of households (and their food security more generally) are rarely wider literature that discusses the international mobility of talent. given much consideration as development objectives and outcomes. Section Three reviews research on the global circulation of health pro- Thirdly, while this debate does seek to understand the drivers of migra- fessionals, focusing in particular upon debates relating to the experience tion, it seems to ignore food shortages and insecurity as a basic cause of of countries in the developing world. Section Four moves the focus from migration and it certainly seems to forget that migrants themselves have international to South African issues and provides new empirical mate- to eat in the towns and cities to which they migrate. Finally, discussions rial drawn from the survey of recruitment patterns and key interviews of migration and development tend to focus more on international than undertaken with health sector recruiters operating in South Africa. internal migration. Food security is certainly affected by international Section Five addresses the questions of changing policy interventions in migration (for example, households in Zimbabwe rely heavily on remit- South Africa towards the outflow of skilled health professionals and the tances from around the world to purchase food and other necessities). recruitment of foreign health professionals to work in South Africa. The However, the relationship between migration and food security is particularly important within national boundaries.

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EXECUTIVEIf StheUMMARY global migration and development debate sidelines food security, the current international food security agenda has a similar disregard for migration. Theealth primary workers focus are oneof the of agendathe categories is food insecurityof skilled profession-and under- nutrition andals how most enhanced affected byagricultural globalization. production Over the by smallpast decade, farmers can resolve thesethere endemic has emerged problems. a 3substantial The influential body ofAlliance research for that a Green tracks Revolution patternsin Africa of (AGRA), international for example, migration was of established health personnel, “to achieve Ha food secure and prosperous Africa through the promotion of rapid, sus- assesses causes and consequences, and debates policy responses at global tainableand national agricultural scales. Withingrowth basedthis literature, on smallholder the case farmers.” of South4 In Africa much is of theattracting thinking growing about ruralinterest. food For insecurity, almost 15 there years is Southan implicit Africa assumption has been thatthe targetAfrica’s of rurala ‘global areas raiding’ are bounded of skilled territories professionals whose bymain several problem devel- is thatoped households countries. Howdo not to produce deal with enough the consequences food for themselves. of the resultant out- flowBy of drawing health professionalsboundaries around is a core the policy “rural” issue in this for way,the nationalthere is agov- tendencyernment. to ignore the reality that migration is a critical food security strategyThis forpaper rural aims households to to examine up and policy down debates the African and issues continent. concerning Any interventionthe migration to of try skilled and improve health professionals the food security from ofthe rural country populations and to thereforefurnish new needs insights to acknowledge on the recruitment that migration patterns both of skilleddeprives health rural per-house- holdssonnel. of Theagricultural objectives labour of the and paper provides are twofold: them with the remittances to purchaseQ +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H agricultural inputs and foodstuffs. Rural households purchase a good dealment of of their skilled food professionals with cash that from they South receive Africa from in absent the health household memberssector. whoThe arepaper working draws inupon other a detailed parts of analysisa country of or recruitment in other countriesadvertising altogether. appearing Rural food in insecurity the South is African therefore Medical not simply Journal about for how muchthe a period household 2000-2004 produces and from a series the ofland; interviews often it conductedis more about with the fact privatethat remittances recruiting from enterprises. migrants are too small or too irregular to allowQ households 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< to purchase sufficient, good quality food. If migrationkey stakeholders is a neglected in the aspect South of Africandiscussions health about sector, rural the food paper insecurity,offers it is a almost series oftotally recommendations absent from considerations for addressing of the the problem causes of and impactskilled of foodhealth security migration. amongst These urban recommendations populations. Many are groundedpoor urban householdsin both South in African African cities experience are made and up an entirely interrogation or partially of inter-of migrants.national Rural to debates urban andmigration ‘good ispolicy’ rarely practice a one-way, for regulatingone-time move, recruit- however.ment. Many urban dwellers speak of and feel attached to a rural home.The Households paper is organized in Africa into are five often sections. spatially Section stretched Two between positions rural anddebates urban about spaces the and migration occupied of skilledby different health members professionals of the withinkin group a atwider different literature times. that The discusses reality onthe the international ground, then, mobility is that of the talent. distinc- tionSection between Three “the reviews rural” research and “the on urban” the global is an circulation“obsolete dichotomy” of health pro- infessionals, Africa.5 focusingAs Ellis andin particular Harris maintain: upon debates “It is not relating very helpfulto the experienceto treat ‘ruralof countries areas’ asin undifferentiatedthe developing world.territories Section that Fourexhibit moves definitively the focus distinct from featuresinternational from ‘urbanto South areas.’” African6 Households issues and are provides not static new self-contained empirical mate- ruralrial drawn or urban from units the butsurvey fluid of entities recruitment with permeablepatterns and boundaries key interviews whose degreeundertaken of food with security health is sectorconstantly recruiters and profoundly operating inshaped South by Africa. the mobil- itySection of people Five inaddresses a continent the questions“on the move.” of changing7 If we policyaccept interventionsthis general in argument,South Africa it immediately towards the becomes outflow ofclear skilled that healthit would professionals be unwise toand drive the arecruitment wedge between of foreign rural andhealth urban professionals food security to work as if theyin South had veryAfrica. little The relationship to or impact on one another. On the contrary, not only are

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EXECUTIVE SUMMARY they inter-related but migration becomes an important key to unlocking this relationship.8 ealth workers are one of the categories of skilled profession- In summary, food security needs to be “mainstreamed” into the migra- als most affected by globalization. Over the past decade, tion and development agenda and migration needs to be “mainstreamed” there has emerged a substantial body of research that tracks into the food security agenda.9 Without such an effort, both agendas will patterns of international migration of health personnel, proceed in ignorance of the other to the detriment of both. The result H will be a singular failure to understand, and manage, the crucial recipro- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is cal relationship between migration and food security. This paper sets out attracting growing interest. For almost 15 years South Africa has been to promote a conversation between the food security and migration agen- the target of a ‘global raiding’ of skilled professionals by several devel- das in the African context in the light of what we know and what we oped countries. How to deal with the consequences of the resultant out- need to know about their connections. Four main issues are singled out flow of health professionals is a core policy issue for the national gov- for attention: (a) the relationship between internal migration and urban ernment. food security; (b) the relationship between international migration and This paper aims to to examine policy debates and issues concerning urban food security; (d) the difference in food security between migrant the migration of skilled health professionals from the country and to and non-migrant urban households; and (d) the role of rural-urban food furnish new insights on the recruitment patterns of skilled health per- transfers in urban food security. Prior to addressing these issues, it is sonnel. The objectives of the paper are twofold: important to disaggregate the complex phenomenon of migration not Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H least because it has been undergoing dramatic change in Africa. ment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for internaL Migration and urban Food Security the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< urbanization and circuLation key stakeholders in the South African health sector, the paper apid urbanization is a distinguishing characteristic of contem- offers a series of recommendations for addressing the problem of porary Africa and a great deal of this urban growth is fuelled by skilled health migration. These recommendations are grounded rural-urban migration. The urban population of SADC in both South African experience and an interrogation of inter- increased from 20.5 million in 1990 to an estimated 34 million national debates and ‘good policy’ practice for regulating recruit- Rin 2010 (Table 1).10 UN-HABITAT predicts that it will increase further ment. to 39 million in 2020 and 52 million in 2030. At the present time, 59% The paper is organized into five sections. Section Two positions of the population is urbanized, a figure projected to pass 70% in the next debates about the migration of skilled health professionals within a 20 years and to rise to over 75% by mid-century (Figure 1). wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health pro- Table 1: Southern African Urban Population, 1950-2050 fessionals, focusing in particular upon debates relating to the experience Population 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 of countries in the developing world. Section Four moves the focus from Urban 5,869 8,277 11,118 14,752 20,502 27,657 34,021 38,809 43,741 48,119 51,917 international to South African issues and provides new empirical mate- (000s) rial drawn from the survey of recruitment patterns and key interviews Urban (%) 37.7 42.0 43.7 44.7 48.8 53.8 58.7 63.5 68.3 72.9 75.0 undertaken with health sector recruiters operating in South Africa. All Africa 14.4 18.6 23.6 27.9 32.1 35.9 39.9 44.6 49.9 55.7 61.6 Section Five addresses the questions of changing policy interventions in (%) South Africa towards the outflow of skilled health professionals and the Source: State of African Cities 2010 recruitment of foreign health professionals to work in South Africa. The

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Figure 1: Southern African Urban Population, 1950-2050 EXECUTIVE SUMMARY 60 000 80 ealth workers are one of the categories of skilled professionals most affected by globalization. Over the past decade, 70 50 000 there has emerged a substantial body of research that tracks patterns of international migration of health personnel, H 60 assesses causes and consequences, and debates policy responses at global 40 000 and national scales. Within this literature, the case of South Africa is 50 attracting growing interest. For almost 15 years South Africa has beenUrban the target of a ‘global raiding’ of skilled professionals by several% devel-(000) 30 000 oped countries. How to deal with the consequences of the40 resultant outflow of health professionals is a core policy issue for the national gov-Urban ernment. 30 (%) 20 000 Population (000s) Population This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country20 and to furnish new insights on the recruitment patterns of skilled health per- 10 000 sonnel. The objectives of the paper are twofold: 10 Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H 0 ment of skilled professionals from South Africa in the0 health 1950 1960sector.1970 1980 The 1990paper2000 draws2010 upon2020 a 2030detailed2040 analysis2050 of recruitment advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with In 1990,private only recruiting South Africa enterprises. was more than 50% urbanized. By 2050, all ofQ the 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< region’s countries except Swaziland are projected to be over 50% urbanizedkey stakeholders (Table 2). inUrbanization the South African rates will health exceed sector, 75% thein Angola, paper Botswanaoffers and a South series Africa.of recommendations Evidence for rapid for addressing urbanization the inproblem Africa of should notskilled be interpreted health migration. as a permanent These recommendations one-time rural-to-urban are grounded shift or that ruralin both areas South are undergoingAfrican experience an inevitable and anprocess interrogation of depopulation. of inter- Certainlynational the overall debates trend and is towards‘good policy’ more practice people living for regulating for longer recruit- peri- ods in townsment. and cities. But this does not mean that they are necessarily cuttingThe allpaper links is toorganized the countryside. into five Indeed,sections. there Section is considerable Two positions evi- dencedebates that about most the first-generation migration of skilled migrants health retain professionals very close tieswithin with a their ruralwider homesteads. literature that This discusses adds considerable the international complexity mobility to our of understandtalent. - ingSection of migration Three reviews dynamics research and impacts. on the global circulation of health professionals,South Africa focusing has in the particular highest proportionupon debates of urbanrelating dwellers to the ofexperience all SADCof countries countries in the (60-70%) developing and world.appears Section closest Fourto the moves model the of focusa classic from 11 “urbaninternational transition.” to South A progressivelyAfrican issues greater and provides proportion new of empirical the population mate- livesrial drawn permanently from the in surveytowns andof recruitment cities, not leastpatterns because and keythe ruralinterviews areas of theundertaken country dowith not health offer householdssector recruiters the prospect operating of ina decentSouth Africa.livelihood 12 orSection many Fivefuture addresses prospects. the questionsThe volume of changingof internal policy migration interventions in South in 13 AfricaSouth grewAfrica rapidly towards after the the outflow collapse of skilledof apartheid-era health professionals influx controls. and the Cumulativerecruitment migrationof foreign (thehealth number professionals of people to living work inin aSouth province Africa. other The than their province of birth) was 5.5 million in 2001, or more than 10%

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EXECUTIVE SUMMARY of the total South African-born population. Internal migration (whether of population in general or of temporary labour migrants) is therefore ealth workers are one of the categories of skilled profession- an extremely significant phenomenon in South Africa. At the municipal als most affected by globalization. Over the past decade, level, most internal migration is towards municipalities that are highly there has emerged a substantial body of research that tracks urbanized (the so-called ‘metros’). The South African Cities Network patterns of international migration of health personnel, calculated that the seven largest urban municipalities in South Africa H attracted over 500,000 additional migrants between 2001 and 2006.14 In assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is five of those areas, these migrants made up over 4% of the total popula- attracting growing interest. For almost 15 years South Africa has been tion (Table 3). the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- Table 2: Southern African Urbanisation, 1950-2050 (% Urbanised) flow of health professionals is a core policy issue for the national gov- Country 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 ernment. Angola 7.6 10.4 15.0 24.3 37.1 49.0 58.5 66.0 71.6 76.4 80.5 This paper aims to to examine policy debates and issues concerning Botswana 2.7 3.1 7.8 16.5 41.9 53.2 61.1 67.6 72.7 77.1 81.7 the migration of skilled health professionals from the country and to Lesotho 1.4 3.4 8.6 11.5 14.0 20.0 26.9 34.6 42.4 50.2 58.1 furnish new insights on the recruitment patterns of skilled health per- Mozambique 2.4 3.7 5.8 13.1 21.1 30.7 38.4 46.3 53.7 60.8 67.4 sonnel. The objectives of the paper are twofold: Namibia 13.4 17.9 22.3 25.1 27.7 32.4 38.0 44.4 51.5 58.6 65.3 Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H South Africa 42.2 46.6 47.8 48.4 52.0 56.9 61.7 66.6 71.3 75.7 79.6 ment of skilled professionals from South Africa in the health Swaziland 1.8 3.9 9.7 17.9 22.9 22.6 21.4 22.3 26.2 32.5 39.5 sector. The paper draws upon a detailed analysis of recruitment Zambia 11.5 18.2 30.4 39.8 39.4 34.8 35.7 38.9 44.7 51.6 53.4 advertising appearing in the South African Medical Journal for Zimbabwe 10.6 12.6 17.4 22.4 29.0 33.8 38.3 43.9 50.7 57.7 64.4 the period 2000-2004 and a series of interviews conducted with Source: State of African Cities 2010 private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< key stakeholders in the South African health sector, the paper Table 3: South African Municipalities Experiencing Greatest In-Migration, 2001-6 offers a series of recommendations for addressing the problem of Name of Municipality Province Net In-Migration Total Pop. in 2006 Recent skilled health migration. These recommendations are grounded In-Migrants as % of Total Pop. in both South African experience and an interrogation of inter- Ekurhuleni Gauteng 140,252 2,384,020 5.9 national debates and ‘good policy’ practice for regulating recruitment. City of Tshwane Gauteng 137,685 1,926,214 7.1 The paper is organized into five sections. Section Two positions City of Cape Town Western Cape 129,400 2,952,385 4.4 debates about the migration of skilled health professionals within a City of Johannesburg Gauteng 120,330 2,993,716 4.0 wider literature that discusses the international mobility of talent. West Rand Gauteng 42,674 732,759 5.8 Section Three reviews research on the global circulation of health pro- eThekwini KwaZulu-Natal 27,277 2,978,811 0.9 fessionals, focusing in particular upon debates relating to the experience Nelson Mandela Eastern Cape 6,715 1,073,114 0.6 of countries in the developing world. Section Four moves the focus from Source: State of the Cities Report 2006, p. 2.18. international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews Simply because urbanization is proceeding rapidly, it does not mean undertaken with health sector recruiters operating in South Africa. that individuals or households who move are cutting their links with Section Five addresses the questions of changing policy interventions in rural areas. How significant a phenomenon is circular migration in South South Africa towards the outflow of skilled health professionals and the Africa and, if so, is it likely to continue?15 The answers to these ques- recruitment of foreign health professionals to work in South Africa. The tions have a significant bearing on both rural and urban food security in the country. Based on their work in rural and peri-urban communities in

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EXECUTIVEthe easternSUMMARY part of the country, Collinson et al argue for the existence of “highly prevalent circular migration” between rural and urban areas and note a markedealth increase workers in aretemporary one of thefemale categories migration. of skilled16 While profession- there does seem toals be most a trend affected towards by globalization. greater permanent Over migrationthe past decade, of households to urbanthere areas, has temporaryemerged a laboursubstantial migration body offrom research rural households that tracks did grow afterpatterns the end of ofinternational apartheid. The migration number of of health rural householdspersonnel, with Hmembers who were migrant workers actually increased in the 1990s and assesses causes and consequences, and debates policy responses at global aand significant national proportion scales. Within of households this literature, are reliant the case on migrantof South remittances. Africa is Inattracting 1993, 33% growing of all interest.rural households For almost reported 15 years at Southleast one Africa migrant has beenmem- ber.the Bytarget 2002, of athis ‘global figure raiding’ had increased of skilled to professionals 38% (an increase by several of 300,000 devel- households).oped countries.17 In How the tolast deal decade, with however,the consequences it appears of that the the resultant number out- of householdsflow of health with professionals migrant workers is a core may policy have begunissue for to thefall nationalas migrants gov- (and households)ernment. settle more permanently in urban areas.18 The number of householdsThis paper with aims an absentto to examine adult member, policy debatesfor example, and issues dropped concerning from 2.2 millionthe migration in 1993 of to skilled 1.6 million health in professionals 2008 (a fall tofrom 30% the of country all households). and to furnishZambia new represents insights on a rather the recruitment different model patterns of the of skilledrelationship health per- betweensonnel. The internal objectives migration of the and paper urbanization. are twofold: The nature of urbanization in ZambiaQ +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H has been a source of debate for years.19 Zambia’s urban population grewment from of skilled3.2 million professionals in 1990 tofrom 3.6 South million Africa in 2000. in the However, health the proportionsector. Theof the paper population draws upon living a indetailed urban areasanalysis actually of recruitment fell from 39% to 35%,advertising prompting appearing researchers in the toSouth conclude African that Medical growing Journal economic for hardshipthe and period urban 2000-2004 poverty was and leading a series to ofa processinterviews of “counter-urban conducted with- ization.”private20 As Potts recruiting concludes, enterprises. “while the fact of net out-migration from urbanQ areas 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< during the 1990s has now been established as a component in the dropkey instakeholders urbanisation in levels,the South it is possibleAfrican tohealth now sector,state that the itpaper was the primaryoffers component”. a series of recommendations21 Zambia’s post-2000 for addressing economic therecovery problem and of growth mayskilled well health have migration.reversed the These counter-urbanization recommendations trend are groundedof the 1990s. Certainlyin both South this is Africanthe view experience of UN-HABITAT and an interrogation which estimates of inter- that urban growthnational rates debates increased and from‘good 1.1% policy’ per practice annum forbetween regulating 1995 recruit- and 2000 to ment.2.3% per annum between 2005 and 2010. Zambia’s Central StatisticalThe paper Office is organizednotes a recent into fiveincrease sections. in rural-rural Section Twoand positionsrural-urban migrationdebates about and athe decline migration in urban-rural of skilled migrationhealth professionals (Figure 2). within22 However, a therewider isliterature every indication that discusses that rural-urban the international linkages mobility remain ofstrong talent. in ZambiaSection andThree will reviews remain research that way on into the the global foreseeable circulation future. of health professionals,Zimbabwe focusing presents in particulara third scenario upon debatesin which relating political to and the economicexperience crisisof countries have precipitated in the developing major shifts world. in Sectioninternal Fourpopulation moves movement.the focus from Duringinternational a relatively to South prosperous African first issues decade and providesof independence new empirical after 1981, mate- rural-urbanrial drawn from migration the survey increased of recruitment rapidly as peoplepatterns sought and key new interviews economic opportunitiesundertaken with in the health country’s sector towns recruiters and cities.operating23 Most in South new urbanites Africa. maintainedSection Five close addresses contact the with questions their rural of changing roots and policy circular interventions migration in wasSouth fairly Africa typical. towards24 In the 1990s,outflow the of skilledcountry’s health Structural professionals Economic and the Programmerecruitment (SAP) of foreign slowed health both professionals the post-independence to work in Southeconomic Africa. boom The and the pace of urbanization.25 Unemployment began to increase but the

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EXECUTIVE SUMMARY urban population still increased by over 1 million between 1990 and 2000 (and from 29% to 34% of the total population). The crisis in the formal ealth workers are one of the categories of skilled profession- urban job market and the serious decline in urban incomes led to net als most affected by globalization. Over the past decade, out-migration from the main towns.26 there has emerged a substantial body of research that tracks patterns of international migration of health personnel, Figure 2: Internal Migration in Zambia, 1996-2006 H 160 000 assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is 140 000 attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- 120 000 oped countries. How to deal with the consequences of the resultant out- 100 000 flow of health professionals is a core policy issue for the national gov- 1996 ernment. 80 000 1998 This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to 60 000 2004 furnish new insights on the recruitment patterns of skilled health per- 40 000 2006 sonnel. The objectives of the paper are twofold: Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H 20 000 ment of skilled professionals from South Africa in the health 0 sector. The paper draws upon a detailed analysis of recruitment Rural to Rural Rural to Urban Urban to Rural Urban to Urban advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with Source: Ianchovichina and Lundstrom, Inclusive Growth in Zambia, p. 4. private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Draconian government policies caused further livelihood destruc- key stakeholders in the South African health sector, the paper tion and internal migration. The forcible expropriation of white-owned offers a series of recommendations for addressing the problem of commercial farms led to massive displacement of black farmworkers to skilled health migration. These recommendations are grounded the towns. That was followed by Operation Murambatsvina, “a lethal in both South African experience and an interrogation of inter- mixture of vindictive electoral politics, a particularly strong attachment national debates and ‘good policy’ practice for regulating recruit- to planned environments, and a wish to reduce the urban population 27 ment. for political and economic reasons.” The nationwide assault on urban The paper is organized into five sections. Section Two positions informality destroyed the housing and livelihoods of hundreds of thou- 28 debates about the migration of skilled health professionals within a sands of urban households. However, it was not particularly successful wider literature that discusses the international mobility of talent. in its aim of forcing urban-dwellers to retreat permanently into the rural Section Three reviews research on the global circulation of health pro- areas. The major difference with Zambia in the 1990s was that many fessionals, focusing in particular upon debates relating to the experience households, both rural and urban, turned to international migration as a 29 of countries in the developing world. Section Four moves the focus from survival strategy. international to South African issues and provides new empirical mate- Deborah Potts has recently reviewed the empirical evidence on rial drawn from the survey of recruitment patterns and key interviews urbanization trends in Sub-Saharan Africa and argues that the idea that 30 undertaken with health sector recruiters operating in South Africa. migration is a permanent move to urban areas is misplaced. Drawing on Section Five addresses the questions of changing policy interventions in a range of empirical sources, and her own longitudinal tracking of migra- South Africa towards the outflow of skilled health professionals and the tion trends in Zimbabwe, she argues that “circulation” between rural and recruitment of foreign health professionals to work in South Africa. The urban areas is still a defining characteristic of African urbanization and internal migration:

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EXECUTIVE SCircularUMMARY migration between rural and urban areas remains a crucial, and adaptable, aspect of urbanization processes in sub-Saharanealth workers Africa… are one The of scale,the categories duration ofand skilled direction profession- of suchals migration most affected flows by have globalization. adapted in Over logical the ways past to decade, the increasingthere povertyhas emerged in urban a substantial areas that body accompanied of research struc that- tracks tural patternsadjustment, of international and net in-migration migration has of beenhealth reduced, personnel, Hsometimes very markedly. These adaptations are mainly the assesses causes and consequences, and debates policy responses at global and nationalresult of scales. very negativeWithin thislivelihood literature, changes the casefor most of South of the Africa is attractingurban growing population interest. for whomFor almost there 15 is noyears economic South Africa safety hasnet, been the targetif all of else a ‘global fails, except raiding’ within of skilled the nexus professionals of rural-urban by several link -developed countries.ages.31 How to deal with the consequences of the resultant out- flowVarious of health household professionals surveys is bya core Potts policy and others issue forsuggest the national that the gov- dynamicsernment. of urbanization, circular migration and rural-urban linkage are complexThis paperand highly aims tovariable. to examine As Potts policy notes, debates “migrants and issues in town concerning include differentthe migration types of skilledpeople healthwith different professionals histories, from aspirations the country and and social to connectionsfurnish new withinsights their on place the recruitmentof origin.”32 patterns of skilled health personnel.Given The the objectives high rates ofof theurbanisation paper are intwofold: Southern Africa, migrants haveQ a visible +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H presence in the region’s towns and cities. AFSUN’s urban food securityment baselineof skilled survey professionals in 2008-9 from found South that Africa poor neighbourhoodsin the health in most sector.cities were The dominatedpaper draws by upon migrants. a detailed33 Of theanalysis 6,453 of urban recruitment households interviewedadvertising in appearing 11 SADC in cities, the South 38% wereAfrican first-generation Medical Journal migrant for householdsthe (thatperiod is, 2000-2004 every member and aof series the household of interviews was conductedborn outside with the city). Inprivate contrast, recruiting only 13% enterprises. of households had no migrant members. The remainderQ 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< (nearly half) comprised a mix of migrants and non-migrants, usually householdskey stakeholders in which in the the South adults Africanwere migrants health andsector, the the children paper were bornoffers in thea series city. ofThe recommendations relative importance for addressingof migrants the did problem vary from of city to city,skilled however. health All migration. of the cities These had recommendations a comparatively smallare grounded proportion of non-migrantin both South households African experience (ranging from and aan low interrogation of 5% in the of case inter- of Gaboronenational to a debateshigh of and20% ‘good in the policy’ case of practice Johannesburg). for regulating In other recruit- words, inment. every city 80% or more of the households were composed either entirelyThe ofpaper migrants is organized or had intosome five migrant sections. members. Section The Two biggest positions difference wasdebates in the about relative the migrationnumber of of migrant skilled householdshealth professionals (from a high within of 67% a in Gaboronewider literature to a low that of discusses9% in Harare). the international mobility of talent. SectionAt a generalThree reviews level these research differences on the are global attributable circulation to eachof health country’s pro- distinctivefessionals, focusinghistory of in urbanisation. particular upon The debates four ex-apartheid relating to cities the experience (Cape Town,of countries Johannesburg, in the developing Msunduzi world.and Windhoek) Section Four all havemoves relatively the focus high from numbersinternational of pure to Southmigrant African households, issues aand pattern provides that newis broadly empirical consistent mate- withrial drawn mass ruralfrom tothe urban survey household of recruitment migration patterns following and keythe collapseinterviews of apartheid.undertaken Cities with inhealth countries sector that recruiters have been operating independent in South for Africa. a longer periodSection (such Five asaddresses Malawi, the Swaziland questions and of Zambia)changing tend policy to haveinterventions more mixed in householdsSouth Africa and towards fewer purelythe outflow migrant of skilledhouseholds. health In professionals those countries, and the independencerecruitment of was foreign accompanied health professionals by rapid in-migration to work in toSouth primate Africa. cities The and those urbanites have been in the cities long enough to have

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EXECUTIVE SUMMARY second and even third generation members born in the city. Mozambique and Zimbabwe became independent rather later and were also severely ealth workers are one of the categories of skilled profession- affected by pre-independence civil conflict and post-independence als most affected by globalization. Over the past decade, economic crisis. These two cities have an extraordinarily high number there has emerged a substantial body of research that tracks of mixed households (nearly 80%). The obvious anomaly in the sur- patterns of international migration of health personnel, vey is Gaborone with two thirds of its households consisting entirely of H migrants. Gaborone has been urbanizing much faster than the either assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is Manzini or Maseru (with which it is often compared) (see Table 4), a attracting growing interest. For almost 15 years South Africa has been reflection of the fact that Botswana’s economy is much more vibrant that the target of a ‘global raiding’ of skilled professionals by several devel- Lesotho or Swaziland’s, drawing more migrant households from the coun- oped countries. How to deal with the consequences of the resultant out- tryside to the city. flow of health professionals is a core policy issue for the national government. Table 4: Proportion of Migrant and Non-Migrant Households This paper aims to to examine policy debates and issues concerning City Migrant Households Mixed Households Non-Migrant Households the migration of skilled health professionals from the country and to (% of Total) (% of Total) (% of Total) furnish new insights on the recruitment patterns of skilled health per- Gaborone 67 28 5 sonnel. The objectives of the paper are twofold: Cape Town 54 40 6 Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Msunduzi 48 43 9 ment of skilled professionals from South Africa in the health Windhoek 49 40 11 sector. The paper draws upon a detailed analysis of recruitment Johannesburg 42 35 23 advertising appearing in the South African Medical Journal for Maseru 37 52 11 the period 2000-2004 and a series of interviews conducted with Manzini 32 55 13 private recruiting enterprises. Lusaka 24 56 20 Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Blantyre 17 65 18 key stakeholders in the South African health sector, the paper Maputo 11 78 11 offers a series of recommendations for addressing the problem of Harare 9 78 13 skilled health migration. These recommendations are grounded Total 38 49 13 in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruitment. Food Security and Stretched houSehoLdS The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a The rural focus of the international and national food security agenda is wider literature that discusses the international mobility of talent. already influencing the way in which the migration-food security nexus Section Three reviews research on the global circulation of health pro- is understood. A recent issue of the journal Food Policy, for example, sug- fessionals, focusing in particular upon debates relating to the experience gests that “the sending of a migrant means the loss or reduced presence of countries in the developing world. Section Four moves the focus from of one or more members of the household. On the consumption side international to South African issues and provides new empirical mate- this clearly means fewer mouths to feed and to support in other ways. rial drawn from the survey of recruitment patterns and key interviews On the production side, migration means the loss of labor and, in fact, undertaken with health sector recruiters operating in South Africa. the negative consequences of migration on nutrition are likely to come Section Five addresses the questions of changing policy interventions in through this labor loss.”34 The major positive impact of migration is the South Africa towards the outflow of skilled health professionals and the remittances sent home by the migrant which can have direct and indi- recruitment of foreign health professionals to work in South Africa. The rect effects on production and consumption.35 Implicit in this analysis is a prioritisation of the impact of migration on the food security of the

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EXECUTIVErural Shousehold.UMMARY This is an important issue, but so is the relationship between migration and the food security of the urban household. A focus on migrant remittancesealth workers will are break one ofthe the conventional categories of notion skilled of profession- the rural household asals wholly most affectedor mainly by dependent globalization. on smallholder Over the past production, decade, but it does not takethere us has far emerged enough ina substantialaddressing bodythe full of rangeresearch of impactsthat tracks that migration haspatterns on food of security,international including migration the food of healthsecurity personnel, of the perma- Hnent and temporary residents of the region’s towns and cities. assesses causes and consequences, and debates policy responses at global andRapid national urbanization scales. Within certainly this effects literature, massive the changecase of Southin the volumeAfrica is andattracting nature growing of what interest.a growing For city almost eats. However,15 years South conceptualizations Africa has been of migrationthe target andof a food‘global security raiding’ need of skilledto take professionals account of the by realityseveral of devel- “highly mobileoped countries. urban and How rural to populations, deal with the coupled consequences with complex, of the resultantfluid house out-- holds.”flow of36 health The concept professionals of the is “stretched a core policy household” issue for seems the national most relevant gov- toernment. breaking down the artificial wall between the urban and the rural and betweenThis paperrural andaims urban to to foodexamine security. policy First, debates it more and closely issues approximatesconcerning athe reality migration in which of skilled migrants health “continue professionals to be members from the of country rural households and to whilstfurnish forming new insights or joining on the other recruitment households patterns in an urban of skilled area.” health37 Secondly, per- itsonnel. emphasizes The objectives the complex of theconnections paper are between twofold: the urban and the rural: QThe +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H notion of a “divide” (between the rural and the urban) hasment become of skilled a misleading professionals metaphor, from oneSouth that Africa oversimplifies in the health andsector. even The distorts paper realities… draws upon The a linkagesdetailed andanalysis interactions of recruitment haveadvertising become appearingan ever more in the intensive South Africanand important Medical com Journal- for ponentthe period of livelihoods 2000-2004 and and production a series of systems interviews in many conducted areas with – privateforming recruiting not so much enterprises. a bridge over a divide as a complex Qweb 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< of connections in a landscape where much is neither “urban”key stakeholders nor “rural.” in38 the South African health sector, the paper offers a series of recommendations for addressing the problem of Thirdly,skilled the healthconcept migration. highlights These the fact recommendations that urban and ruralare grounded food security inare both often South inter-dependent African experience at the level and ofan the interrogation individual houseof inter-- hold. national debates and ‘good policy’ practice for regulating recruit- As urban-urbanment. migration increases (for example, from smaller urban centresThe topaper large is cities)organized within into countries five sections. and across Section borders, Two positions“stretched households”debates about are the also migration emerging of in skilled the purely health urban professionals context. withinIn Lesotho, a forwider example, literature many that households discusses thein the international capital city mobilityof Maseru of havetalent. mem- bersSection working Three in reviewsSouth African research towns on the and global cities. circulation The National of health Migration pro- Surveyfessionals, in Namibia focusing foundin particular that urban-urban upon debates migration relating made to the up experience 20% of 39 lifetimeof countries migration in the moves. developing In Southworld. Africa, Section the Four “fluidity, moves porosity the focus and from spatiallyinternational ‘stretched’ to South nature African of households” issues and hasprovides been observed.new empirical Household mate- fluidityrial drawn relates from to the the survey “contested of recruitment nature” of patterns household and membership, key interviews the claimsundertaken of non-core with health urban sector household recruiters members operating on household in South resources Africa. andSection the “spatiallyFive addresses extended the questionsnature of ofthe changing links and policy resource interventions flows thus in 40 created.”South Africa As towards a result, the the outflow density ofof skilledexchanges health between professionals the two and (pri -the marilyrecruitment of people, of foreign goods, health cash and professionals social grants) to work impacts in South on the Africa. food secu The- rity of stretched households:

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EXECUTIVE SUMMARY These (migrant) exchanges, networks and resource flows play a key role in alleviating the effects of poverty and man- ealth workers are one of the categories of skilled profession- aging vulnerability. They help households and household als most affected by globalization. Over the past decade, members to take advantage of opportunities and to diffuse there has emerged a substantial body of research that tracks risk across space. Ties to urban beneficiaries are a vital patterns of international migration of health personnel, source of income for rural households in the context of ever- H present monetisation and when living even in the country- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is side requires cash. For urban dwellers, the possibility of enti- attracting growing interest. For almost 15 years South Africa has been tlements from rural households serves as a vital livelihood the target of a ‘global raiding’ of skilled professionals by several devel- ‘cushion’, particularly if the rural kin have access to land or oped countries. How to deal with the consequences of the resultant out- are able to care for children while parents seek employment flow of health professionals is a core policy issue for the national gov- in urban centres.41 ernment. Increasingly, multi-nodal households are emerging, “stretched” This paper aims to to examine policy debates and issues concerning between two or more locations. In Maputo, poor urban households are the migration of skilled health professionals from the country and to stretched to include the Mozambican countryside and urban areas in furnish new insights on the recruitment patterns of skilled health per- South Africa: sonnel. The objectives of the paper are twofold: Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H The urban poor in Maputo survive through a variety of ment of skilled professionals from South Africa in the health strategies. The use of kinship networks is a principal strat- sector. The paper draws upon a detailed analysis of recruitment egy, in which ‘non-market solidarities’ are activated in the advertising appearing in the South African Medical Journal for face of the failure of the state. The development of multiple the period 2000-2004 and a series of interviews conducted with household strategies, and the dispersal of family members private recruiting enterprises. geographically is one such strategy. A network of exchanges Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< is developed between the households, with members in key stakeholders in the South African health sector, the paper town exchanging goods and services with households in the offers a series of recommendations for addressing the problem of countryside. Members of the family may migrate to neigh- skilled health migration. These recommendations are grounded bouring countries such as South Africa in order to spread in both South African experience and an interrogation of inter- the risk and diversify the sources of survival. Faced with the national debates and ‘good policy’ practice for regulating recruit- exigencies of survival there is a tension between the need for ment. family cohesion and the pull of dispersal. The dissolution of The paper is organized into five sections. Section Two positions traditional social bonds has been a cause of enormous inse- debates about the migration of skilled health professionals within a curity and social vulnerability.42 wider literature that discusses the international mobility of talent. Even in a small country like Lesotho, household members are dis- Section Three reviews research on the global circulation of health pro- persed by migration yet maintain strong social and material links with fessionals, focusing in particular upon debates relating to the experience one another: of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical mate- The Basotho are integrated together in a fluid shifting rial drawn from the survey of recruitment patterns and key interviews ensemble of people, where members of the same family undertaken with health sector recruiters operating in South Africa. may have a relative managing sheep and goats in the upper Section Five addresses the questions of changing policy interventions in Senqu Valley in Lesotho, while his brother cultivates moun- South Africa towards the outflow of skilled health professionals and the tain wheat and keeps a home ready for the herdsman when recruitment of foreign health professionals to work in South Africa. The he comes down for the winter. They have a sister who has married in the lowlands, where she struggles to grow maize on an exhausted piece of eroded land. Her husband is fortu-

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EXECUTIVE SnateUMMARY to work in the South African mines, and comes home monthly. When he was younger he brought cattle back homeealth from workersthe mines, are butone now of the as hecategories has grown of skilledolder he profession- prefersals to most bring affected money byand globalization. food and household Over the goods. past decade,Most of histhere remittances has emerged are spent a substantial on food, clothing,body of research education that and tracks medicalpatterns expenses. of international They have another migration brother of health who personnel,teaches Hschool in a peri-urban community near Mafeteng and two assesses causes and consequences, and debates policy responses at global and nationalyounger scales. sisters: Within one who this works literature, as a domestic the case inof Durban,South Africa is attractingSouth growing Africa, interest. and another For almost who works 15 years in a South textile Africa factory has been the targetin Maseru. of a ‘global Both raiding’ support of themselves skilled professionals but also send by moneyseveral developed countries.home. The How sister to recently deal with married the consequences a policeman ofin thethe resultantcity outflow ofof health Bloemfontein, professionals South is Africa,a core policyand is issuewaiting for untilthe national he finds government.a place for both of them so she can move there. An uncle Thisin paperBloemfontein aims to towho examine took permanent policy debates residence and issuesin South concerning the migrationAfrica when of skilled he retired health from professionals the mines fromis helping the country them find and to furnisha newplace insights to live. onAll the of theserecruitment folk visit patterns each other of skilled regularly, health so personnel.that The there objectives is a constant of the flowpaper from are twofold:mountain to lowland to Qtown +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H to South African city and back.43 In otherment words, of skilled a “household” professionals may from well South have migrantAfrica in members the health living, workingsector. and otherwise The paper making draws do upon in more a detailed than oneanalysis city inof therecruitment country or region.advertising This adds appearing yet another in layerthe South of complexity African Medicaland fluidity Journal to house for - hold foodthe security period strategies.2000-2004 and a series of interviews conducted with private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< key stakeholders in the South African health sector, the paper South-Southoffers Migration a series of recommendationsand Food Security for addressing the problem of skilled health migration. These recommendations are grounded changing Migrationin both SSouthtrea MSAfrican experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- riorment. to the 1990s, most international migration in the Southern The Africanpaper is regionorganized involved into fiveyoung, sections. mostly Section male, labour Two positions migrants debates movingabout the temporarily migration to of another skilled healthcountry professionals to work in primary within indusa - wider literaturetry such thatas mining discusses and thecommercial international agriculture. mobility This of talent.form of P“circular migration” began in the late nineteenth century and became Section Three reviews research on the global circulation of health pro- entrenchedfessionals, focusing in the twentieth. in particular44 The upon system debates was relating closely regulatedto the experience by gov- ernmentsof countries and in employers the developing who ensured world. Sectionthat other Four family moves and the household focus from membersinternational remained to South behind African in the issues country and ofprovides origin. Mostnew empirical migrants weremate- warehousedrial drawn from in single-sex the survey dormitories of recruitment on mines patterns or farms and keywhere interviews they wereundertaken fed high-protein with health diets sector by employers. recruiters 45operating Migrants in remitted South Africa. most of theirSection earnings Five addresses to rural households the questions who of used changing the funds policy to interventionspay taxes and in purchaseSouth Africa basic towards necessities. the outflowEmployers of skilledpaid low health wages professionals on the assumption and the thatrecruitment the rural of household foreign health would professionals produce food to to work feed in itself. South This Africa. practice The became less tenable as the twentieth century progressed and the sub-

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EXECUTIVE SUMMARY continent’s rural areas became more degraded and incapable of support- ing the population through agriculture. The inevitable result was that ealth workers are one of the categories of skilled profession- in many areas the food security of rural households became increasingly als most affected by globalization. Over the past decade, dependent on migrant remittances. there has emerged a substantial body of research that tracks Since 1990, Southern Africa’s longstanding regime of temporary cross- patterns of international migration of health personnel, border migration has undergone major transformation.46 The reconfigu- H ration of migration streams has considerable implications for urban and assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is rural food security and the migrants who shuttle between town and coun- attracting growing interest. For almost 15 years South Africa has been tryside. In order to understand the complex inter-relationships between the target of a ‘global raiding’ of skilled professionals by several devel- mobility and food security, it is therefore necessary to understand the oped countries. How to deal with the consequences of the resultant out- different types of migration that make up the contemporary migration flow of health professionals is a core policy issue for the national gov- regime of a region ‘on the move.’ Firstly, since 1990, there has been a ernment. dramatic increase in legal cross-border migration to and within Southern This paper aims to to examine policy debates and issues concerning Africa. Traffic between South Africa and the rest of Africa increased the migration of skilled health professionals from the country and to from around 1 million in 1990 to nearly 10 million in 2008 (Figure 3). furnish new insights on the recruitment patterns of skilled health per- Increased mobility has also been observed at numerous other borders sonnel. The objectives of the paper are twofold: across the SADC region. There are now some migrants from each SADC Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H country in every other SADC country. ment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment Figure 3: Legal Entries to South Africa from Rest of Africa, 1990-2010 advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with 8 000 000 private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 7 000 000 key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of 6 000 000 skilled health migration. These recommendations are grounded in both South African experience and an interrogation of inter- 5 000 000 national debates and ‘good policy’ practice for regulating recruitment. 4 000 000 The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a 3 000 000 wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health pro- 2 000 000 fessionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from 1 000 000 international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews 0 undertaken with health sector recruiters operating in South Africa.

Section Five addresses the questions of changing policy interventions in 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 South Africa towards the outflow of skilled health professionals and the Source: Statistics South Africa recruitment of foreign health professionals to work in South Africa. The

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EXECUTIVEZimbabweSUMMARY has become the major migrant sending country in Southern Africa in the last two decades. The vast majority of these migrants are in South Africaealth with workers smaller are numbersone of the in categoriesother SADC of skilledcountries profession- and in Europe andals Northmost affected America. by Theglobalization. number of Over Zimbabweans the past decade,crossing legally into Souththere has Africa emerged increased a substantial from under body 200,000 of research per annum that tracks in the late 1980spatterns to 1.5 of million international in 2010 migration(Figure 4). of In health addition, personnel, there are Han unknown number of undocumented migrants who cross the border assesses causes and consequences, and debates policy responses at global throughand national unofficial scales. channels. Within Zimbabweanthis literature, migrants the case maintain of South very Africa close is tiesattracting with the growing country, interest. remitting For considerablealmost 15 years sums South of money Africa and has quanti been- tiesthe oftarget goods of toa ‘globalhousehold raiding’ members of skilled still professionalsin the country. by Most several engage devel- in circularoped countries. migration How and to return deal withhome the frequently. consequences In a 2006 of the survey, resultant SAMP out- foundflow of that health 31% professionals return to Zimbabwe is a core atpolicy least issueonce fora month the national and 76% gov- at leasternment. once a year.47 This paper aims to to examine policy debates and issues concerning Figure 4: Legalthe Entriesmigration from ofZimbabwe skilled healthto South professionals Africa, 1980-2010 from the country and to 1 600 000 furnish new insights on the recruitment patterns of skilled health personnel. The objectives of the paper are twofold: 1 400 000 Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H ment of skilled professionals from South Africa in the health 1 200 000 sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for 1 000 000 the period 2000-2004 and a series of interviews conducted with

800 000 private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 600 000 key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of 400 000 skilled health migration. These recommendations are grounded in both South African experience and an interrogation of inter- 200 000 national debates and ‘good policy’ practice for regulating recruitment. 0 The paper is organized into five sections. Section Two positions

debates1980 1981 1982 about1983 1984 1985 the1986 1987 migration1988 1989 1990 1991 of1992 skilled1993 1994 1995 health1996 1997 1998 professionals1999 2000 2001 2002 2003 within2004 2005 2006 2007 a 2008 2009 2010 wider literature that discusses the international mobility of talent. Source: StatisticsSection South Africa Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience Circular migration is also a defining characteristic of migrants who of countries in the developing world. Section Four moves the focus from move to South Africa from other countries in the SADC region. The international to South African issues and provides new empirical mate- numbers of migrants from all the other countries in the region have rial drawn from the survey of recruitment patterns and key interviews grown consistently since 1994. Those from Malawi, Mozambique and undertaken with health sector recruiters operating in South Africa. Lesotho come in the greatest numbers. As the Lesotho case demon- Section Five addresses the questions of changing policy interventions in strates, this is not just a case of growing numbers but involves complex South Africa towards the outflow of skilled health professionals and the reconfigurations in who migrates, where and why.48 For decades, cross- recruitment of foreign health professionals to work in South Africa. The border migration from Lesotho to South Africa was primarily undertaken by young males who went to work on the South African gold mines. This

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EXECUTIVE SUMMARY decades-old pattern began to break down in the 1980s and 1990s when the mining industry closed mines and retrenched Basotho migrant work- ealth workers are one of the categories of skilled profession- ers in considerable numbers. In response, more women began to migrate als most affected by globalization. Over the past decade, for work within and outside the country. In South Africa, women tend to there has emerged a substantial body of research that tracks work in two sectors known for their lack of regulation and labour rights: patterns of international migration of health personnel, commercial farms and domestic work.49 Within Lesotho, the growth of H a domestic textile industry in the country’s urban centres has led to a assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is major upsurge in the internal migration of young women (Figure 5). attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- Figure 5: Male Employment in South African Mines and Female Employment in Lesotho Garment Factories, 1990-2006 oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- 120 000 ernment. This paper aims to to examine policy debates and issues concerning 100 000 the migration of skilled health professionals from the country and to Mine 80 000 furnish new insights on the recruitment patterns of skilled health per- Workers sonnel. The objectives of the paper are twofold: Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H 60 000 Textile ment of skilled professionals from South Africa in the health Workers sector. The paper draws upon a detailed analysis of recruitment 40 000 advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with 20 000 private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 0 1992 1990 1991 1994 1995 1996 1997 1998 1999 2000 2001 2003 2004 2005 2006 key stakeholders in the South African health sector, the paper 1993 2002 offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded A household survey by SAMP in 2006 in Botswana, Lesotho, in both South African experience and an interrogation of inter- Mozambique, Swaziland and Zimbabwe showed that minework in South national debates and ‘good policy’ practice for regulating recruit- Africa still constitutes a significant component of the cross-border migra- ment. tion flow (Table 5).50 The occupational profile of Zimbabwean migrants The paper is organized into five sections. Section Two positions is far more diverse than migrants from the other countries, with very few debates about the migration of skilled health professionals within a mineworkers from that country: wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health pro- The contemporary migration flow from Zimbabwe is fessionals, focusing in particular upon debates relating to the experience extremely “mixed” compared with pre-1990 out-migration of countries in the developing world. Section Four moves the focus from and with that from other countries in the Southern African international to South African issues and provides new empirical mate- region. There are almost as many women migrants as men; rial drawn from the survey of recruitment patterns and key interviews there are migrants of all ages from young children to the old undertaken with health sector recruiters operating in South Africa. and firm; those fleeing hunger and poverty join those fleeing Section Five addresses the questions of changing policy interventions in persecution and harassment; they are from all rungs of the South Africa towards the outflow of skilled health professionals and the occupational and socioeconomic ladder; they are highly-read recruitment of foreign health professionals to work in South Africa. The and illiterate, professionals and paupers, doctors and ditch- diggers.51

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ETableXECUTIVE 5: OccupationsSUMMARY of Labour Migrants in South Africa, 2006 Occupation Country of Origin Botswanaealth workersLesotho are oneMozam- of the categoriesSwaziland ofZimbabwe skilled profession-Total % %als most affected % bybique globalization. % % Over the %past decade, Professional there has emerged a substantial body of research that tracks Professional 1.6patterns of2.9 international1.7 migration3.5 of health14.7 personnel,4.8 worker H assesses causes and consequences, and debates policy responses at global Health workerand national0.6 scales. 0.3Within this0.3 literature, 0.5the case of10.6 South Africa2.3 is Employer/ attracting0.0 growing interest.0.0 For 0.0almost 15 years0.4 South 1.3Africa has been0.3 Manager the target of a ‘global raiding’ of skilled professionals by several devel- Teacher oped countries.0.0 How0.1 to deal with0.1 the consequences0.8 of7.0 the resultant1.5 out- Farmer flow of health1.1 professionals0.3 is a 0.1core policy 0.4issue for the0.7 national gov-0.5 Businessman/ernment.0.6 1.2 4.0 1.1 4.2 2.2 woman This paper aims to to examine policy debates and issues concerning White Collarthe migration of skilled health professionals from the country and to Office Managerfurnish new0.3 insights 0.2on the recruitment0.0 patterns0.8 of skilled3.5 health 0.9per- Office Workersonnel. The1.1 objectives0.3 of the paper0.4 are twofold:1.7 4.6 1.5 Blue Collar Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Skilled manual ment0.8 of skilled6.2 professionals8.0 from South6.1 Africa4.9 in the health5.6 Foreman sector.0.6 The paper0.1 draws 0.5upon a detailed0.7 analysis0.5 of recruitment0.5 Police/Military advertising0.2 appearing0.0 in0.1 the South 0.2African Medical0.4 Journal0.1 for Security the0.0 period 2000-20040.2 and0.5 a series of1.9 interviews0.1 conducted0.6 with Mineworker private87.2 recruiting68.4 enterprises.30.5 62.3 3.0 49.5 Farmworker Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H<0.2 2.0 2.2 0.5 1.2 1.3 Service worker key1.1 stakeholders1.1 in the South1.2 African2.5 health sector,9.9 the paper3.1 Unskilled offers a series of recommendations for addressing the problem of Domestic skilled1.7 health9.0 migration.0.9 These recommendations1.6 1.9 are grounded3.2 worker in both South African experience and an interrogation of inter- Unskilled national0.5 debates1.5 and ‘good9.5 policy’ practice7.8 for 2.1regulating recruit-4.7 manual ment. Informal EconomyThe paper is organized into five sections. Section Two positions Informal prodebates- about0.2 the migration2.8 of skilled0.8 health0.4 professionals4.8 within 1.8a ducer wider literature that discusses the international mobility of talent. Trader/hawker/Section Three0.0 reviews2.0 research 6.0on the global0.7 circulation14.7 of health4.6 pro- vendor fessionals, focusing in particular upon debates relating to the experience Other of countries0.8 in the developing0.0 16.9world. Section4.3 Four moves2.9 the focus5.3 from N international633 to South1,076 African 987issues and1,132 provides new857 empirical4,685 mate- Source: SAMPrial Data drawn Base from the survey of recruitment patterns and key interviews undertaken with health sector recruiters operating in South Africa. SectionMinework Five addressesis still important the questions for Mozambicans of changing but policy they, interventions too, have in anSouth increasingly Africa towards diverse the occupational outflow of profile.skilled Inhealth general, professionals however, andthe the migrantrecruitment stream of foreignfrom all health countries professionals is dominated to work by blue in Southcollar, Africa.unskilled The and informal economy migrants. These migrants come from households

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EXECUTIVE SUMMARY in their home countries that are heavily dependent on migrant remittances to meet basic needs and are likely to be more food insecure than ealth workers are one of the categories of skilled profession- their better-resourced counterparts. A central question that therefore als most affected by globalization. Over the past decade, needs to be addressed is whether migrant-sending households are more there has emerged a substantial body of research that tracks or less food secure than households that do not send migrants. Another patterns of international migration of health personnel, important question is the food security experience of migrants themselves H at their place of destination. Since many work in low-wage sectors and assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is jobs, and the cost of living is much higher in cities, it is likely that they attracting growing interest. For almost 15 years South Africa has been are also vulnerable to food insecurity when away from home. the target of a ‘global raiding’ of skilled professionals by several devel- The number of labour migrants working without official work per- oped countries. How to deal with the consequences of the resultant out- mits and/or residency status within the countries of SADC is difficult flow of health professionals is a core policy issue for the national gov- to determine. Despite very high rates of domestic unemployment, ernment. most irregular migrants do seem able to find jobs or income-generating This paper aims to to examine policy debates and issues concerning opportunities. A 2010 SAMP study of recent Zimbabwean migrants in the migration of skilled health professionals from the country and to South Africa, for example, found that 21% were working in the informal furnish new insights on the recruitment patterns of skilled health per- economy, 10% were working part-time and 53% full-time. Only 14% sonnel. The objectives of the paper are twofold: were unemployed.52 In South Africa, employers in sectors such as com- Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H mercial agriculture, construction and domestic work actually prefer non- ment of skilled professionals from South Africa in the health South African workers (since they can subvert labour laws, avoid paying sector. The paper draws upon a detailed analysis of recruitment benefits and violate minimum wage legislation).53 The primary policy advertising appearing in the South African Medical Journal for response to irregular migration is summary arrest and deportation.54 the period 2000-2004 and a series of interviews conducted with Since 1990, just over 3 million migrants have been deported from South private recruiting enterprises. Africa (Figure 6). The vast majority (97%) of deportees come from other Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< SADC countries (with Mozambique and Zimbabwe making up 90% of key stakeholders in the South African health sector, the paper the total), leading some to question the cost effectiveness of this strat- offers a series of recommendations for addressing the problem of egy. Deportation in such massive numbers is not generally viewed as a skilled health migration. These recommendations are grounded form of “migration” yet it does involve (forced) movement and can have in both South African experience and an interrogation of inter- major impacts on the livelihoods and food security of deportees and their national debates and ‘good policy’ practice for regulating recruit- households. ment. The paper is organized into five sections. Section Two positions Figure 6: Deportations from South Africa, 1990-2008 debates about the migration of skilled health professionals within a 350 000 wider literature that discusses the international mobility of talent. 300 000 Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience 250 000 of countries in the developing world. Section Four moves the focus from 200 000 international to South African issues and provides new empirical mate- 150 000 rial drawn from the survey of recruitment patterns and key interviews 100 000 undertaken with health sector recruiters operating in South Africa. 50 000 Section Five addresses the questions of changing policy interventions in 0 South Africa towards the outflow of skilled health professionals and the 2001 2004 2007 2008 1997 recruitment of foreign health professionals to work in South Africa. The 1990 1991 1992 1993 1994 1995 1996 1998 1999 2000 2002 2003 2005 2006

Source: Department of Home Affairs

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EXECUTIVETheSUMMARY SADC region has experienced several waves of mass “forced migration” in recent decades. Over 3 million refugees fled Mozambique in the 1980sealth to refugee workers camps are one in Malawi, of the categories South Africa of skilled and in profession- Zimbabwe. In South Africa,als most many affected refugees by eventuallyglobalization. settled Over and the were past integrated decade, into local ruralthere and has urban emerged communities. a substantial The body war inof researchAngola also that led tracks to mass movementspatterns of refugeesof international to neighbours migration Zambia of health and Namibia. personnel, More Hrecently, other “conflict hotspots” in Africa have produced an influx of assesses causes and consequences, and debates policy responses at global asylumand national seekers scales. to the Within countries this of literature, Southern theAfrica. case In of SouthSouth Africa,Africa ais totalattracting of 150,000 growing asylum interest. applications For almost were 15 received years South by the Africa Department has been ofthe Home target Affairs of a ‘global between raiding’ 1994 ofand skilled 2004 professionals (Table 6). In bythe several same period,devel- onlyoped 27,000 countries. applicants How to were deal granted with the refugee consequences status. In of January the resultant 2011, out- theflow UNHCR of health estimated professionals that isrefugee a core status policy had issue been for grantedthe national to around gov- 53,000ernment. applicants in the whole post-apartheid period. However, the refugee Thisdetermination paper aims process to to examine is so backlogged policy debates that asylum and issues decisions concerning tend to bethe taken migration on the of basis skilled of thehealth country professionals of origin fromrather the than country the individual and to circumstancesfurnish new insights of the onclaimant. the recruitment As a result, patterns asylum of seekers skilled from health countries per- likesonnel. Somalia The andobjectives DRC haveof the found paper it areeasier twofold: to get refugee status than thoseQ from +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H other African countries, such as Zimbabwe.55 Sincement 2004, of the skilled number professionals of applications from Southfor refugee Africa status in the has health dramatically increased.sector. The This paper is partially draws becauseupon a detailedirregular analysis migrants of have recruitment start- ing usingadvertising the system appearing to legitimize in the their South status African in South Medical Africa Journal and avoid for deportation.the period In 2009, 2000-2004 for example, and athere series were of interviews 220,028 new conducted applications with for refugeeprivate status recruiting (Table 7). enterprises. In that year, 45,538 applications were reject- ed andQ only 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 4,531 were accepted. Of these 75% were from three countries (thekey DRC, stakeholders Ethiopia inand the Somalia). South African The number health of sector, registered the paperasylum seekers inoffers the acountry series of at recommendations that time was around for addressing 420,000. Zimbabwe the problem is of now theskilled leading health country migration. of refugee These claimants recommendations in South Africa are (149,000grounded or 68% ofin allboth applications South African in 2009) experience followed and by anMalawi interrogation (16,000 or of 7%).inter- In 2009,national only 200 debates Zimbabweans and ‘good were policy’ granted practice refugee for status regulating while recruit-15,370 applicationsment. were refused. RefugeesThe paper are is permittedorganized byinto South five sections.African law Section to work Two and positions earn income.debates 56about The thesituation migration of asylum-seekers of skilled health is much professionals more precarious: within a “Asylumwider literature seekers thatare not discusses allowed the to international work and thus mobility have no of means talent. to supportSection themselves,Three reviews if they research do need on thesupport global they circulation have to approach of health gov pro-- ernmentfessionals, structures. focusing inAsylum particular seekers upon have debates no rights relating to food, to the work, experience health careof countries or education.” in the 57developing In practice, world. asylum-seekers Section Four have moves to live the and focus many from thereforeinternational resort to to South the informal African economyissues and or provides irregular new employment empirical inmate- orderrial drawn to make from ends the meetsurvey while of recruitment they wait (sometimes patterns and interminably) key interviews for theirundertaken claims towith be healthadjudicated. sector Clearly,recruiters though, operating refugees in South and asylumAfrica. seek- ersSection do not Five enjoy addresses the same the rights, questions levels of of changing well-being policy and interventionspossibilities of in accessSouth toAfrica food towardssecurity. the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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EXECUTIVE SUMMARY Table 6: Refugee Applications in South Africa by Country of Origin, 1994-2004 Country Applications ealth workers are one of the categories of skilled profession- Number % als most affected by globalization. Over the past decade, Africa DRC* 24 808 15.7 there has emerged a substantial body of research that tracks Angola* 12 192 7.7 Hpatterns of international migration of health personnel, Somalia 14 998 9.5 assesses causes and consequences, and debates policy responses at global Nigeria 12 219 7.7 and national scales. Within this literature, the case of South Africa is Kenya 10 553 6.7 attracting growing interest. For almost 15 years South Africa has been Zimbabwe* 6 857 4.3 the target of a ‘global raiding’ of skilled professionals by several devel- Ethiopia 6 537 4.1 oped countries. How to deal with the consequences of the resultant out- Tanzania* 4 821 3.1 flow of health professionals is a core policy issue for the national gov- Senegal 4 724 3.0 ernment. This paper aims to to examine policy debates and issues concerning Burundi 4 570 2.9 the migration of skilled health professionals from the country and to Congo-Brazzaville 3 823 2.4 furnish new insights on the recruitment patterns of skilled health per- Malawi* 2 765 1.8 sonnel. The objectives of the paper are twofold: Rwanda 2 167 1.4 Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Ghana 2 114 1.3 ment of skilled professionals from South Africa in the health Cameroon 2 011 1.3 sector. The paper draws upon a detailed analysis of recruitment Ivory Coast 1 006 0.6 advertising appearing in the South African Medical Journal for Asia Pakistan 12 576 8.0 the period 2000-2004 and a series of interviews conducted with India 10 472 6.6 private recruiting enterprises. Bangladesh 4 173 2.6 Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< China 2 846 1.8 key stakeholders in the South African health sector, the paper Bulgaria 1 616 1.0 offers a series of recommendations for addressing the problem of Others 10 098 6.4 skilled health migration. These recommendations are grounded Total 157 946 100.0 in both South African experience and an interrogation of inter- * = SADC Countries national debates and ‘good policy’ practice for regulating recruit- Source: Department of Home Affairs ment. The paper is organized into five sections. Section Two positions The treatment of migrants in destination countries is another impor- debates about the migration of skilled health professionals within a tant determinant of income generating opportunities and therefore of wider literature that discusses the international mobility of talent. individual and household food security. Until recently, anti-immigrant Section Three reviews research on the global circulation of health pro- hostility and xenophobia was largely seen as a Northern plague.58 fessionals, focusing in particular upon debates relating to the experience However, it is becoming increasingly evident that this phenomenon is of countries in the developing world. Section Four moves the focus from also increasingly common in migrant-receiving countries in the South.59 international to South African issues and provides new empirical mate- South Africa is one of the most migrant-intolerant countries in the world rial drawn from the survey of recruitment patterns and key interviews and xenophobic attitudes and actions are distressingly common.60 In May undertaken with health sector recruiters operating in South Africa. 2008, xenophobic violence swept the country’s poor urban communities, Section Five addresses the questions of changing policy interventions in leaving over 60 people dead and over 100,000 displaced.61 Damage to South Africa towards the outflow of skilled health professionals and the the property and businesses of migrants ran into the millions of rands. recruitment of foreign health professionals to work in South Africa. The The violence destroyed the livelihoods of many migrants (who were corralled in makeshift refugee camps) and led to a dramatic increase in

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EXECUTIVEpersonalSUMMARY insecurity and hardship for migrant-sending households in other countries. While this scale of violence has not been repeated, attacks on foreign-ownedealth businesses workers continueare one of in the many categories areas. The of skilled specific profession- connec- tions betweenals xenophobia,most affected disrupted by globalization. livelihoods Over and the food past insecurity decade, have not yet beenthere examined. has emerged However, a substantial in general, body any ofanalysis research of thethat relation tracks- ship betweenpatterns migration of international and food security migration needs ofto health consider personnel, the impact Hof poor and abusive treatment of migrants by citizens, officialdom and assesses causes and consequences, and debates policy responses at global employers.and national scales. Within this literature, the case of South Africa is attracting growing interest. For almost 15 years South Africa has been Table 7: Refugeethe target Applications of a ‘global and Decisions raiding’ inof Southskilled Africa, professionals 2009 by several developed countries.Applications How to deal with theAccepted consequences of theRefused resultant out- Zimbabwe flow of health149,453 professionals is a core policy200 issue for the national15,370 gov- Malawi ernment. 15,697 0 7,749 Ethiopia This paper10,715 aims to to examine policy1,307 debates and issues3,130 concerning DRC the migration6,226 of skilled health professionals779 from the country1,706 and to Bangladeshfurnish new 4,923insights on the recruitment31 patterns of skilled 3,310health per- India sonnel. The 3,632objectives of the paper are0 twofold: 1,045 Somalia Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H3,580 1,213 638 China ment3,327 of skilled professionals from0 South Africa in the1,634 health Congo sector.3,223 The paper draws upon613 a detailed analysis of 1,391recruitment Pakistan advertising3,196 appearing in the South0 African Medical1,770 Journal for Nigeria the period3,023 2000-2004 and a series0 of interviews conducted2,046 with Mozambique private2,559 recruiting enterprises. 0 882 Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Tanzania 1,739 0 602 key stakeholders in the South African health sector, the paper Niger 1,445 0 1,071 offers a series of recommendations for addressing the problem of Uganda 1,425 20 759 skilled health migration. These recommendations are grounded Burundi in both1,208 South African experience133 and an interrogation367 of inter- Zambia national1,000 debates and ‘good policy’0 practice for regulating266 recruit- Ghana ment. 942 0 648 Cameroon The paper 667is organized into five sections.9 Section Two positions429 Kenya debates about 624the migration of skilled health0 professionals within276 a Angola wider literature335 that discusses the international7 mobility of talent.132 Rwanda Section Three275 reviews research on the17 global circulation of health68 pro- Lesotho fessionals, focusing258 in particular upon debates0 relating to the 54experience Eritrea of countries in219 the developing world.202 Section Four moves the71 focus from Senegal international to204 South African issues and0 provides new empirical74 mate- Algeria rial drawn from133 the survey of recruitment0 patterns and key interviews50 Totals undertaken220,028 with health sector recruiters4,531 operating in South45,538 Africa. Source: UNHCRSection Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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EXECUTIVE SUMMARY croSS-border Migration and urban Food Security The simplest way to examine the relationship between cross-border ealth workers are one of the categories of skilled profession- migration and food security is to ascertain (a) how international migrants als most affected by globalization. Over the past decade, address their own food and nutrition needs in the destination country there has emerged a substantial body of research that tracks and (b) what happens to the income they earn while away from home. patterns of international migration of health personnel, H The two questions are not unrelated for the amount of money avail- assesses causes and consequences, and debates policy responses at global able to send home is to some degree contingent on the food-related and national scales. Within this literature, the case of South Africa is expenditures of the migrant in the destination country. This is not as sim- attracting growing interest. For almost 15 years South Africa has been ple as it sounds because the food-related draw on income in the destina- the target of a ‘global raiding’ of skilled professionals by several devel- tion country may extend well beyond the individual migrant’s own needs. oped countries. How to deal with the consequences of the resultant out- Migrants rarely live alone and their income may often have to support flow of health professionals is a core policy issue for the national gov- members of “makeshift” households (not all of whose members can find ernment. work) as well as second households. One of the recurrent complaints of This paper aims to to examine policy debates and issues concerning the partners of male migrants in Lesotho and Mozambique, for example, the migration of skilled health professionals from the country and to is that they receive less money because the migrants support second fami- furnish new insights on the recruitment patterns of skilled health per- lies in South Africa as well.62 sonnel. The objectives of the paper are twofold: SAMP has conducted major household surveys in several SADC Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H countries and provides valuable information on food expenditures in ment of skilled professionals from South Africa in the health migrant-sending households.63 Table 8 shows the sources of income for sector. The paper draws upon a detailed analysis of recruitment a regional sample of 4,276 households with international migrants. Cash advertising appearing in the South African Medical Journal for remittances are the most important source of income in all countries the period 2000-2004 and a series of interviews conducted with with 74% of all migrant-sending households receiving remittances (with private recruiting enterprises. as many as 95% in Lesotho and 83% in Zimbabwe). In-country wage Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< employment is a source of income for 40% of households followed by key stakeholders in the South African health sector, the paper remittances in kind (37%). Remittances in-kind are particularly impor- offers a series of recommendations for addressing the problem of tant in Zimbabwe and Mozambique. At the other end of the spectrum, skilled health migration. These recommendations are grounded only 8% of households receive income from the sale of agricultural pro- in both South African experience and an interrogation of inter- duce and only 5% receive social grants (mainly in Botswana). national debates and ‘good policy’ practice for regulating recruitment. The paper is organized into five sections. Section Two positions Table 8: Income Sources of Migrant Households, 2006 (% of Households) debates about the migration of skilled health professionals within a Botswana Lesotho Mozambique Swaziland Zimbabwe Total wider literature that discusses the international mobility of talent. Wage work 87 9 34 46 57 40 Section Three reviews research on the global circulation of health pro- Casual work 12 6 13 2 11 8 fessionals, focusing in particular upon debates relating to the experience Remittances – money 76 95 77 64 83 74 of countries in the developing world. Section Four moves the focus from Remittances – goods 53 20 65 17 68 37 international to South African issues and provides new empirical mate- Sale of farm products 5 2 21 9 3 8 rial drawn from the survey of recruitment patterns and key interviews Formal business 5 1 4 3 4 4 undertaken with health sector recruiters operating in South Africa. Informal business 9 5 23 14 17 12 Section Five addresses the questions of changing policy interventions in Pension/ 19 0.5 3 2 3 5 South Africa towards the outflow of skilled health professionals and the disability grant recruitment of foreign health professionals to work in South Africa. The Gifts 2 1.5 3 3 2 3 Other 1 0 3 1 0.5 1 Source: SAMP 1 26 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESerieS NnOo. 4560

EXECUTIVERemittancesSUMMARY and in-country employment are easily the most important sources of household income (an average R400 per month for each). However, asealth noted, workers far more are households one of the receivecategories income of skilled from profession-remittances than in-countryals most employment. affected by globalization. Over the past decade, The vastthere majority has ofemerged households a substantial (93%) purchase body of researchfood and that groceries tracks with their incomepatterns (Table of international 9). No other migration expenditure of health category personnel, comes close Halthough a significant minority of households pay for cooking fuel, trans- assesses causes and consequences, and debates policy responses at global portation,and national clothing, scales. utilities, Within educationthis literature, and medicalthe case expenses.of South AfricaA mere is 15%attracting spend growing income interest.on agricultural For almost inputs 15 (mainly years South in Swaziland). Africa has The been proportionthe target ofof ahouseholds ‘global raiding’ spending of skilled remittances professionals on food by was several over devel-80%. Averageoped countries. household How expenditures to deal with on the food consequences were R288 perof the month resultant which out- is muchflow of greater health than professionals the amounts is a corespent policy on other issue common for the nationalcategories gov- such asernment. transportation, education and medical expenses. The average monthly expenditureThis paper of aimsremittances to to examine on food policy was R150 debates per andmonth. issues In concerningother words, remittancesthe migration provided of skilled over health 50% professionalsof average household from the income country spent and toon food.furnish Without new insights remittances on the the recruitment amount being patterns spent of on skilled food healthwould dropper- precipitously.sonnel. The objectives Remittances of theare papertherefore are atwofold: critical component of food securityQ +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=Hfor migrant-sending households. Unsurprisingly, 82% of households saidment that of remittances skilled professionals were “very from important” South Africa and another in the health18% that they weresector. “important” The paper to meetingdraws upon household a detailed food analysis needs. of recruitment advertising appearing in the South African Medical Journal for Table 9: Monthly Expensesthe period of Migrant-Sending 2000-2004 and Households a series of interviews conducted with Expenditure Item private% of recruiting Households enterprises. % of Households Average Monthly Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H

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EXECUTIVE SUMMARY The study found that 28% of households spend more than 60% of their income on food. This varied considerably from country to coun- ealth workers are one of the categories of skilled profession- try ranging from 13% in the case of Zimbabwe to 40% in the case of als most affected by globalization. Over the past decade, Mozambique. Even with remittances, only 17% said that they had always there has emerged a substantial body of research that tracks or almost always had enough food in the previous year. Again this varied patterns of international migration of health personnel, from country to country with only 2% of households in Zimbabwe saying H they always or almost always had enough food. Mozambique returned the assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is highest figure, but still only 24%. attracting growing interest. For almost 15 years South Africa has been Cash remittances are not the only way in which migration contributes the target of a ‘global raiding’ of skilled professionals by several devel- to household security as many migrants also send food back home as part oped countries. How to deal with the consequences of the resultant out- of their in-kind remittance “package.” Further proof of the importance of flow of health professionals is a core policy issue for the national gov- migration to household food security and other basic needs is provided ernment. in the types of goods that migrants send home. There was little evi- This paper aims to to examine policy debates and issues concerning dence of luxury goods being sent. Instead, clothing (received by 41% of the migration of skilled health professionals from the country and to households) and food (received by 29%) were the items most frequently furnish new insights on the recruitment patterns of skilled health per- brought or sent. In the case of Mozambique, 60% of households received sonnel. The objectives of the paper are twofold: food and in Zimbabwe, 45%. Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H ment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment MigrantS and Food Security advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with he next question addressed in this paper is whether migrants private recruiting enterprises. are more food insecure than longer term residents of the poorer Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< areas of Southern African cities. The question is a difficult key stakeholders in the South African health sector, the paper one to answer definitively for a number of reasons. First, there Tis the point already made that the food security of the urban and rural offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded members of a household are inter-linked. One of the main reasons for in both South African experience and an interrogation of inter- temporary migration to urban areas is to earn income to remit to rural national debates and ‘good policy’ practice for regulating recruit- household members. A migrant in the city may sacrifice their own food ment. security in order to remit and ensure that rural relatives have enough to The paper is organized into five sections. Section Two positions eat. Secondly, in a region in which the majority of the food consumed by debates about the migration of skilled health professionals within a urban households is purchased, the food security of the migrant is highly wider literature that discusses the international mobility of talent. contingent on their ability to earn income in the urban formal or infor- Section Three reviews research on the global circulation of health pro- mal economy. Thirdly, there may be significant differences between inter- fessionals, focusing in particular upon debates relating to the experience nal and cross-border migrants in terms of access to urban employment of countries in the developing world. Section Four moves the focus from and other income-generating activity. All of these issues require much international to South African issues and provides new empirical mate- further research before we can draw definitive conclusions. However, rial drawn from the survey of recruitment patterns and key interviews there is suggestive case study evidence for some cities. undertaken with health sector recruiters operating in South Africa. Recent studies of food security and migration in Johannesburg and Section Five addresses the questions of changing policy interventions in Windhoek provide an opportunity to compare the food security of inter- South Africa towards the outflow of skilled health professionals and the nal and international migrant households.64 The Johannesburg study recruitment of foreign health professionals to work in South Africa. The interviewed 487 households, of whom 60% were internal migrants and the rest international migrants (mainly from Zimbabwe). Three quarters

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EXECUTIVEof theS internalUMMARY migrants were living in an informal settlement (compared to only 11% of cross-border migrants). Most of the cross-border migrants (86%) livedealth in the workers inner-city are oftenone of in the multi-household categories of skilled flats. Just profession- over half of the householdsals most sent affected money by outside globalization. the city. Over Another the past21% decade,sent food. Cross-borderthere migrants has emerged in the inner-city a substantial were body more of likely research to remit that cashtracks (60% versuspatterns 38% of ofhouseholds) international and migrationfood (30% of versus health 6%) personnel, than internal Hmigrants in the informal settlement. In terms of food security, 49% said assesses causes and consequences, and debates policy responses at global thatand nationaltheir food scales. access Within had improved this literature, since moving the case to ofJohannesburg South Africa while is onlyattracting 19% feltgrowing that it interest. had deteriorated. For almost However, 15 years Southcross-border Africa migrantshas been werethe target more oflikely a ‘global to report raiding’ an improvement of skilled professionals than internal by severalmigrants. devel- The latteroped countries.were also moreHow likelyto deal to with report the that consequences they had experienced of the resultant food out- shortagesflow of health in the professionals previous year is (68%a core versus policy 56%). issue forDietary the national diversity gov- was alsoernment. poorer amongst internal migrants. Clearly, migration may mean improvedThis paper food aimsaccess to but to examineit does not policy guarantee debates that and shortages issues concerning will not bethe experienced. migration of Unreliable skilled health income professionals was cited frommost theoften country by both and sets to of migrantsfurnish new as the insights reason on for the food recruitment shortages. patterns of skilled health personnel.The WindhoekThe objectives study of interviewed the paper are a total twofold: of 513 migrant heads of householdQ +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H living in formal and informal settlements. The majority (98%) were internalment ofmigrants, skilled professionalsmostly from the from Northern South Africa regions in of the the health country. Money issector. remitted The to paper rural draws areas uponby 54% a detailed of the respondents, analysis of recruitment and 90% of the moneyadvertising is sent appearing to rural areas in the in Souththe North. African Neither Medical food Journal nor goods for are sent thein any period quantity 2000-2004 although and most a series migrants of interviews said that conducted the bulk ofwith the money theyprivate sent recruiting was spent enterprises. on food. There was no evidence of any cor- relationQ 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H

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EXECUTIVE SUMMARY from regular wage work. This suggests that migrants are no more or less likely to obtain wage employment than permanent residents in the city, a ealth workers are one of the categories of skilled profession- finding of some significance since it is often assumed that migrants have als most affected by globalization. Over the past decade, a harder time finding work than those born and bred in a city. there has emerged a substantial body of research that tracks Migrant households do seem to find it easier to derive income from patterns of international migration of health personnel, casual work (Table 10, Figure 7). A number of other small differences H emerged. First, non-migrant households were more involved than assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is migrant households in running informal and formal businesses (20% attracting growing interest. For almost 15 years South Africa has been versus 14%). This suggests it may be easier for permanent residents of the target of a ‘global raiding’ of skilled professionals by several devel- the city to access the resources (such as credit) to run and grow a busi- oped countries. How to deal with the consequences of the resultant out- ness. Secondly, although very few households in either category earn any flow of health professionals is a core policy issue for the national gov- income from the sale of home-grown agricultural produce, non-migrant ernment. households did seem a little more likely to engage in urban agriculture, This paper aims to to examine policy debates and issues concerning presumably because they have readier access to land through home the migration of skilled health professionals from the country and to ownership. Thirdly, migrant households were slightly more likely than furnish new insights on the recruitment patterns of skilled health per- non-migrant households to be receiving social grant income (19% versus sonnel. The objectives of the paper are twofold: 16%). The difference is not large but it suggests that migrant households Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H eligible to receive social grants are able to access them even if they are ment of skilled professionals from South Africa in the health not in their home area. sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for Table 10: Sources of Household Income the period 2000-2004 and a series of interviews conducted with Migrant Households (%) Non-Migrant Households (%) private recruiting enterprises. Wage Work 51.2 54.4 Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Casual Work 24.2 20.1 key stakeholders in the South African health sector, the paper Remittances 8.0 8.4 offers a series of recommendations for addressing the problem of Urban Agriculture Products 1.0 3.2 skilled health migration. These recommendations are grounded Formal Business 3.5 4.1 in both South African experience and an interrogation of inter- Informal Business 10.5 15.9 national debates and ‘good policy’ practice for regulating recruit- Rent 4.0 5.5 ment. Social Grants 19.3 15.6 The paper is organized into five sections. Section Two positions N 2,425 801 debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. The similarities in the access of migrant and non-migrant households Section Three reviews research on the global circulation of health pro- to the labour market and to various income-generating activities suggests fessionals, focusing in particular upon debates relating to the experience that they might have similar income levels and, in turn, levels of food of countries in the developing world. Section Four moves the focus from security. In fact, there was one distinct difference in the income profile international to South African issues and provides new empirical mate- of migrant and non-migrant households (Figure 8). About a third of the rial drawn from the survey of recruitment patterns and key interviews households in each group fell into the lowest income tercile. However, undertaken with health sector recruiters operating in South Africa. 36% of non-migrant households were in the upper income tercile, com- Section Five addresses the questions of changing policy interventions in pared to only 29% of migrant households. The situation was reversed South Africa towards the outflow of skilled health professionals and the with the middle income tercile. In other words, migrant status is not a recruitment of foreign health professionals to work in South Africa. The completely reliable predictor of whether a household will be income poor. However, non-migrant households are likely to have a better chance of

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EXECUTIVEhavingS UMMARYbetter incomes, primarily because some are able to access better- paying jobs. ealth workers are one of the categories of skilled profession- Figure 7: Sources of Householdals most Income affected by globalization. Over the past decade, there has emerged a substantial body of research that tracks 60 Hpatterns of international migration of health personnel, 50 assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is 40 attracting growing interest. For almost 15 years South Africa has been

30 the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- Percentage 20 flow of health professionals is a core policy issue for the national government. Migrant 10 Household This paper aims to to examine policy debates and issues concerningNon-Migrant 0 the migration of skilled health professionals from the countryHousehold and to

furnish new insights on the recruitment patternsRent of skilled health personnel. The objectives of the paper are twofold: Wage Work Wage Casual Work Casual Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=HRemittances Social Grants

Formal Business Formal

ment of skilled professionals from South Africa in the health Informal Business sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for

the period 2000-2004Products UrbanAgriculture and a series of interviews conducted with private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Figure 8: Income Tercileskey stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded Lowest Income in both South African experience and an interrogation of inter- Tercile national debates and ‘good policy’ practice for regulating recruitment. Migrant Household The paper is organized into five sections. Section Two positions Non-Migrant Middle Incomedebates about the migration of skilled health professionals withinHousehold a Tercile wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from Highest Incomeinternational to South African issues and provides new empirical mate- Tercile rial drawn from the survey of recruitment patterns and key interviews undertaken with health sector recruiters operating in South Africa. Section0 Five addresses10 the questions20 of changing30 policy interventions in South Africa towards Percentagethe outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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EXECUTIVE SUMMARY Since urban households purchase the bulk of their food, non-migrant households might have a better chance of being food secure than migrant ealth workers are one of the categories of skilled profession- households. The Household Food Insecurity Scale (HFIAS) measures als most affected by globalization. Over the past decade, access to food on a 0 (most secure) to 27 (most insecure) point scale. there has emerged a substantial body of research that tracks The mean and median score for all households in the survey was 10, sug- patterns of international migration of health personnel, gesting widespread food insecurity. Individual city means varied from a H low of 5 in Johannesburg to a high of 15 in Harare.65 In terms of the rela- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is tionship between the HFIAS and food security, migrant households had attracting growing interest. For almost 15 years South Africa has been a mean score of 10.5 and a median of 10. Non-migrant households had the target of a ‘global raiding’ of skilled professionals by several devel- lower scores of 8.9 and 8 respectively. Although the differences are not oped countries. How to deal with the consequences of the resultant out- massive, the results confirm that non-migrant households have a better flow of health professionals is a core policy issue for the national gov- chance of being food secure than migrant households. ernment. This finding is given added weight by the Household Food Insecurity This paper aims to to examine policy debates and issues concerning Access Prevalence (HFIAP) Indicator. Only 16% of migrant households the migration of skilled health professionals from the country and to can be categorized as “food secure” using the HFIAP Indicator, com- furnish new insights on the recruitment patterns of skilled health per- pared with 26% of non-migrant households (Figure 9). At the opposite sonnel. The objectives of the paper are twofold: end of the scale, 61% of migrant households were severely food insecure, Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H compared with only 48% of non-migrant households. Or again, 78% ment of skilled professionals from South Africa in the health of migrant households are either moderately or severely food insecure, sector. The paper draws upon a detailed analysis of recruitment compared with 65% of non-migrant households. Although levels of food advertising appearing in the South African Medical Journal for insecurity are disturbingly high for both types of household, migrant the period 2000-2004 and a series of interviews conducted with households stand a greater chance of being food insecure. private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Figure 9: Food Security of Migrant and Non-Migrant Households key stakeholders in the South African health sector, the paper 70 offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded 60 in both South African experience and an interrogation of inter- 50 national debates and ‘good policy’ practice for regulating recruit- 40 Migrant Household ment. 30

The paper is organized into five sections. Section Two positions Percentage Non-Migrant Household 20 debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. 10 0 Section Three reviews research on the global circulation of health pro- Food Mildly Food Moderately Severely Food fessionals, focusing in particular upon debates relating to the experience Secure Insecure Food Insecure Insecure of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical mate- Another dimension of food insecurity is dietary diversity. The rial drawn from the survey of recruitment patterns and key interviews Household Dietary Diversity Scale (HDDS) measures how many food undertaken with health sector recruiters operating in South Africa. groups have been eaten by household members in the previous 24 hours Section Five addresses the questions of changing policy interventions in (up to a maximum of 12). Most poor migrant and non-migrant house- South Africa towards the outflow of skilled health professionals and the holds do not have a particularly diverse diet. For example, nearly half recruitment of foreign health professionals to work in South Africa. The of both groups consumed food from 5 or fewer food groups, and nearly a quarter from 3 or fewer food groups. The main difference between

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EXECUTIVEthe twoSUMMARY groups comes at the other end of the scale where diverse diets are more frequent among non-migrant than migrant households. For example, 28%ealth of migrantworkers householdsare one of the consumed categories food of fromskilled 7 orprofession- more food groups,als compared most affected with 38%by globalization. of all non-migrant Over thehouseholds. past decade, In other words,there non-migrant has emerged households a substantial are generally body of likelyresearch to have that atracks more diverse diet.patterns of international migration of health personnel, HAnother question is whether there are any differences between assesses causes and consequences, and debates policy responses at global migrantand national and non-migrant scales. Within households this literature, in where the theycase obtainof South their Africa food isin theattracting city. Here growing some interest.interesting For differences almost 15 emerged.years South Migrant Africa households has been werethe target more oflikely a ‘global than non-migrantraiding’ of skilled households professionals to patronise by several supermarkets. devel- Theoped opposite countries. was How true to with deal regard with theto the consequences informal food of economy.the resultant The out- reasonflow of forhealth this differenceprofessionals is not is a immediately core policy issueapparent for the but national may have gov- to do withernment. the fact that non-migrant households would be more familiar with alternativeThis paper food aims sources to to compared examine policywith recent debates in-migrants, and issues in concerning particular,the whomigration would ofbe skilled more likelyhealth to professionals know about fromand recognise the country supermarket and to outlets.furnish newA second insights difference on the recruitmentis the extent patterns to which of households skilled health rely per-on othersonnel. households The objectives for food, of theeither paper through are twofold: sharing meals or food transfers. ThisQ was +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H more common among migrant than non-migrant households, suggestingment the of existence skilled professionals of stronger social from networksSouth Africa amongst in the migrants. health Thirdly, sector.and unsurprisingly The paper draws given upon their a greater detailed degree analysis of access of recruitment to land for gardens,advertising non-migrant appearing households in the were South more African likely to Medical grown someJournal of theirfor own foodthe than period migrant 2000-2004 households. and a series of interviews conducted with private recruiting enterprises. Table 11: HouseholdQ 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Dietary Diversity No. of Food Groups key stakeholdersMigrant Households in the (cum South %) AfricanNon-Migrant health sector,Households the (cum paper %) 1 offers a series of recommendations3 for addressing 4the problem of 2 skilled health migration.14 These recommendations14 are grounded 3 in both South African24 experience and an interrogation23 of international debates and ‘good policy’ practice for regulating recruit- 4 34 33 ment. 47 45 5 The paper is organized into five sections. Section Two positions 6 debates about the migration59 of skilled health professionals56 within a 7 wider literature that discusses71 the international mobility66 of talent. 8 Section Three reviews research83 on the global circulation78 of health pro- 9 fessionals, focusing in particular91 upon debates relating to86 the experience 10 of countries in the developing95 world. Section Four moves91 the focus from 11 international to South African97 issues and provides new 95empirical material drawn from the survey of recruitment patterns and key interviews 12 100 100 undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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EXECUTIVE SUMMARY Figure 10: Sources of Food for Migrant and Non-Migrant Households 90 ealth workers are one of the categories of skilled profession- 80 70 als most affected by globalization. Over the past decade, Migrant 60 80 Household there has emerged a substantial body of research that tracks 50 patterns of international migration of health personnel, 40 Non-Migrant H Household assesses causes and consequences, and debates policy responses at global 30 and national scales. Within this literature, the case of South Africa is 20 attracting growing interest. For almost 15 years South Africa has been 10 the target of a ‘global raiding’ of skilled professionals by several devel- 0 oped countries. How to deal with the consequences of the resultant out-

flow of health professionals is a core policy issue for the national gov- Aid Food

ernment. Food Borrow Small Outlets Supermarkets This paper aims to to examine policy debates and issues concerning Urban Agriculture the migration of skilled health professionals from the country and to Remittances Food

furnish new insights on the recruitment patterns of skilled health per- Economy Informal Food Community Food Kitchen Food Community Food Provided by Other by HH Provided Food

sonnel. The objectives of the paper are twofold: Sharing Meals with Other HH

Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H ment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment Migration and Food tranSFerS advertising appearing in the South African Medical Journal for he rural and urban nodes in stretched households are linked by the period 2000-2004 and a series of interviews conducted with flows of people, cash, goods and information. There is evidence private recruiting enterprises. that urban households in Africa rely to varying degrees on an Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< informal, non-marketed supply of food from their rural (and key stakeholders in the South African health sector, the paper Turban) relatives in order to survive within hostile urban environments.66 offers a series of recommendations for addressing the problem of In one documented case, Windhoek, the contribution turned out to be skilled health migration. These recommendations are grounded extremely significant.67 Frayne’s study of 305 poor urban households in both South African experience and an interrogation of inter- found that poverty was widespread and accompanied by high rates of national debates and ‘good policy’ practice for regulating recruit- unemployment. In addition, casual work was not commonly available for ment. low-income residents. The informal sector was much more limited than The paper is organized into five sections. Section Two positions in other cities in the region and urban agriculture was scant and provided debates about the migration of skilled health professionals within a little contribution to household food security. Only 5% of the sample wider literature that discusses the international mobility of talent. were involved in some form of urban agriculture. Yet there was no wide- Section Three reviews research on the global circulation of health pro- spread starvation and little malnutrition. Only 9% of households said fessionals, focusing in particular upon debates relating to the experience that hunger was always or almost always a problem. of countries in the developing world. Section Four moves the focus from The primary asset that ameliorated the food insecurity of urban international to South African issues and provides new empirical mate- households proved to be urban-rural social networks. The resources rial drawn from the survey of recruitment patterns and key interviews required to satisfy food and other needs come predominantly from the undertaken with health sector recruiters operating in South Africa. rural areas direct to the urban household. The most vulnerable house- Section Five addresses the questions of changing policy interventions in holds were those that had poor rural connections. However, 98% of the South Africa towards the outflow of skilled health professionals and the households had relatives in the rural areas. Two-thirds of the households recruitment of foreign health professionals to work in South Africa. The received food from relatives and friends in the year prior to the survey. Nearly 60% received food 2-6 times a year. Another study of Windhoek

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EXECUTIVEin 2008SUMMARY found that 44% of households interviewed in the poorer parts of the city received food from outside the city and that 99% of this food was sent by familyealth members. workers Furthermore, are one of the 73% categories of this food of skilled was sent profession- from the Northern regions.als most The affected food received by globalization. by the urban Over household the past decade, included millet, wild therefoods has(especially emerged spinach), a substantial meat, body poultry of researchand fish. that The tracks vast majority of householdspatterns of international(90%) consumed migration the food of themselveshealth personnel, with only H6% selling it and 4% giving it away to other relatives and friends. In assesses causes and consequences, and debates policy responses at global Windhoek,and national therefore, scales. Within urban foodthis literature,security for the economically case of South marginal Africa is householdsattracting growing was dependent interest. “to For a almostlarge degree” 15 years on South the transfer Africa ofhas food been fromthe target rural ofrelatives: a ‘global raiding’ of skilled professionals by several developed countries.The flow ofHow goods to dealbetween with the the urban consequences and rural of areas the resultantis outflow oftruly health reciprocal. professionals With isabout a core two policy thirds issue of urban for the households national government.both sending money to the rural areas and receiving food Thisfrom paper rural aims households, to to examine the rural-urban policy debates symbiosis and issues is well- concerning the migrationestablished. of skilled Unless health there professionalsis rapid economic from growththe country with jobsand to furnishfor new unskilled insights and on semi-skilledthe recruitment workers patterns in Windhoek, of skilled thehealth flow personnel.of The food objectives into the urban of the areas paper is arelikely twofold: to continue as urban Qhouseholds +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H continue to diversify their sources of food and income.ment of68 skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment In theadvertising case of Maputo, appearing the inurban the Southpoor maintain African “aMedical close and Journal con- for scious relationship”the period 2000-2004 with their ruraland a area series of oforigin: interviews conducted with Theyprivate argue recruiting that it is enterprises. important to maintain relationships Qwith 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< relatives and others in the village, and that being involvedkey stakeholders in agriculture in the is importantSouth African as “we health do not sector, have the to paper spendoffers so a muchseries ofmoney recommendations on food.” Having for addressingmachambas the in theproblem of villageskilled is healthconsidered migration. the best These option recommendations as this attaches peopleare grounded toin their both extended South African family, experiencebut many also and have an interrogation small plots on of inter- thenational outskirts debates of Maputo and ‘good or in policy’the bairro practice itself. 69for regulating recruitment. In Harare, too, migrants to the city maintain strong social and mate- The paper is organized into five sections. Section Two positions rial connections with the rural areas. In the past, the established practice debates about the migration of skilled health professionals within a was for urban households to send money and supplementary food to the wider literature that discusses the international mobility of talent. rural areas. However, economic hardships in the city are now making it Section Three reviews research on the global circulation of health pro- difficult for these flows to continue.70 Many urban households maintain fessionals, focusing in particular upon debates relating to the experience small plots of land in the village where they grow crops or keep animals. of countries in the developing world. Section Four moves the focus from The importance of these activities has grown with the food crisis in the international to South African issues and provides new empirical mate- cities. By engaging in rural farming, urban household members contribute rial drawn from the survey of recruitment patterns and key interviews to generating the food that they eat when they visit the countryside or undertaken with health sector recruiters operating in South Africa. sell to get a supplementary income that they can use in both the rural Section Five addresses the questions of changing policy interventions in and urban area. A 2008 survey in Harare found that 35% of respondents South Africa towards the outflow of skilled health professionals and the normally visit the rural areas to engage in farming activity.71 As many as recruitment of foreign health professionals to work in South Africa. The 64% of household respondents also reported that they normally visit their rural homes to collect food and/or money. The economic crisis in that

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EXECUTIVE SUMMARY country has, however, reconfigured the nature of these relationships and flows. Urban households are increasingly getting more from the village ealth workers are one of the categories of skilled profession- than they send, suggesting that the flow of resources between the rural als most affected by globalization. Over the past decade, and the urban area has reversed. The net urban-ward flow of resources, there has emerged a substantial body of research that tracks and especially food, is partly responsible for the resilience of poor house- patterns of international migration of health personnel, holds in the city. More than half of the households surveyed (61%) H received food from the rural areas. The most common foods transferred assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is from the rural areas included cereals (54% of households), root and attracting growing interest. For almost 15 years South Africa has been tubers (36%), meat and poultry (26%) and food made from beans and the target of a ‘global raiding’ of skilled professionals by several devel- nuts (16%) (Figure 11). The high cost of transport between the rural and oped countries. How to deal with the consequences of the resultant out- the urban areas meant that the majority of food transfers were only tak- flow of health professionals is a core policy issue for the national gov- ing place 3-6 times a year or even less frequently. Another crisis-related ernment. response involved members of the urban household migrating back to the This paper aims to to examine policy debates and issues concerning rural areas of Zimbabwe. the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health per- Figure 11: Type and Frequency of Rural-Urban Food Transfers to Harare sonnel. The objectives of the paper are twofold: 60 Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H ment of skilled professionals from South Africa in the health 50 sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for 40 the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. 30 Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 20 key stakeholders in the South African health sector, the paper % of Households offers a series of recommendations for addressing the problem of 10 skilled health migration. These recommendations are grounded in both South African experience and an interrogation of inter- 0 Cereals/ Roots Vege- Fruits Meat / Eggs Fresh Foods Cheese, Foods Sugar national debates and ‘good policy’ practice for regulating recruit- food or tables poultry or dried made yoghurt, made or ment. from tubers or o!al "sh from milk with fat, honey grains beans, products oil or The paper is organized into five sections. Section Two positions peas, butter debates about the migration of skilled health professionals within a Kind of food received nuts wider literature that discusses the international mobility of talent. At least once a week At least once every 2 months 3–6 times a year At least once a year Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from Source: Tawodzera, 2010. international to South African issues and provides new empirical mate- The prevalence of rural-urban food linkages in other parts of the rial drawn from the survey of recruitment patterns and key interviews Southern African region needs more systematic investigation.72 With undertaken with health sector recruiters operating in South Africa. this in mind, the 2008-9 AFSUN baseline survey included a number of Section Five addresses the questions of changing policy interventions in questions about food transfers in the 11 cities in which the survey was South Africa towards the outflow of skilled health professionals and the conducted.73 recruitment of foreign health professionals to work in South Africa. The Almost one in three of the poor urban households surveyed by AFSUN said they receive food from relatives or friends outside the city.

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EXECUTIVEThe foodSUMMARY flows from relatives make up over 90% of the total. The study confirmed the significance of food transfers in Windhoek with 47% of households ealthreceiving workers food are from one outside of the the categories city. Transfers of skilled were profession- also very significant inals Lusaka most affected (44%), Harareby globalization. (42%), Maseru Over (37%),the past Blantyre decade, (36%) and Manzinithere has (35%) emerged (Figure a substantial 12). By contrast, body of researchand not unexpectthat tracks- edly given thepatterns impoverished of international state of Southmigration Africa’s of health communal personnel, land Hareas, the proportion of urban households receiving food transfers was assesses causes and consequences, and debates policy responses at global muchand national lower in scales. the three Within South this African literature, cities the surveyed. case of SouthWhile Africafood trans is - fersattracting from rural growing areas interest. were certainly For almost significant 15 years (41% South of allAfrica households has been receivingthe target transfers), of a ‘global the raiding’ survey ofmade skilled the professionals important finding by several that evendevel- moreoped countries.transfers (48%) How occurredto deal with between the consequences households in of different the resultant urban out- areas.flow of The health remainder professionals received is afood core from policy both issue rural for and the othernational urban gov- areas.ernment. Once again, clear differences emerged between different cities. HouseholdsThis paper in aimsWindhoek to to examineand Gaborone policy weredebates at oneand end issues of concerningthe spectrum,the migration with around of skilled 70% ofhealth transfers professionals emanating from from the rural country areas. and to furnish new insights on the recruitment patterns of skilled health per- Figure 12: Totalsonnel. Food The Transfers objectives to Urban of Householdsthe paper are(% oftwofold: Households) 50 47 Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H 45 44 42 40 ment of skilled professionals from South Africa in the health 37 35 36 35 sector. The paper draws upon a detailed analysis of recruitment 30 28 advertising appearing in the South African Medical 24 Journal for 25 22 23 20 the period 2000-2004 and a series of interviews 18 conducted with 15 private recruiting enterprises. 14 10 5 Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 0 key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of Total Harare Lusaka Maseru Maputo Manzini skilled health migration.Blantyre These recommendations are grounded Msunduzi Gaborone Windhoek Cape Town Cape

in both South African experience and an interrogation of inter-

Johannesburg national debates and ‘good policy’ practice for regulating recruit-

ment. The relative importance of rural-urban versus urban-urban food The paper is organized into five sections. Section Two positions transfers varied considerably from city to city. Rural transfers to house- debates about the migration of skilled health professionals within a holds in Windhoek made up 72% of total transfers while urban-urban wider literature that discusses the international mobility of talent. transfers made up only 12%. At the other end of the spectrum were the Section Three reviews research on the global circulation of health pro- South African cities. Cape Town, for example, had figures of 14% for fessionals, focusing in particular upon debates relating to the experience rural-urban and 83% for urban-urban transfers. Some 82% of transfers of countries in the developing world. Section Four moves the focus from to Msunduzi and 62% of transfers to Johannesburg were also from other international to South African issues and provides new empirical mate- urban areas outside these cities. The South African pattern reflects sev- rial drawn from the survey of recruitment patterns and key interviews eral things. First, South Africa is the most urbanized of the nine countries undertaken with health sector recruiters operating in South Africa. in the study. Secondly, South Africa’s rural areas are so impoverished that Section Five addresses the questions of changing policy interventions in they do not produce excess food that can be sent to support migrants in South Africa towards the outflow of skilled health professionals and the the city. And thirdly, social networks and ties between relatives in differ- recruitment of foreign health professionals to work in South Africa. The ent cities are strong. The figures for the cities in major migrant-sending countries are also

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EXECUTIVE SUMMARY significant. In Maputo, for example, 62% of transfers are urban-urban. High rates of urban-urban food transfer can also be found in Blantyre ealth workers are one of the categories of skilled profession- (51%), Maseru (44%), Lusaka (44%) and Harare (43%). In each case, als most affected by globalization. Over the past decade, it is likely that a large proportion of transfers come in the form of food there has emerged a substantial body of research that tracks remittances where migrants working in one city (often in another coun- patterns of international migration of health personnel, try) send food to their relatives living in another urban area (often in H their home country). assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is attracting growing interest. For almost 15 years South Africa has been Table 12: Food Transfers by City (% of Households) the target of a ‘global raiding’ of skilled professionals by several devel- Wind- Gabo- Manzini Maseru Lusaka Blan- Harare Joburg Maputo Msun- Cape hoek rone tyre duzi Town oped countries. How to deal with the consequences of the resultant out- Rural- 72 70 53 49 39 38 37 24 23 15 14 flow of health professionals is a core policy issue for the national gov- Urban ernment. Transfers This paper aims to to examine policy debates and issues concerning Urban- 12 16 40 44 44 51 43 67 62 82 83 Urban the migration of skilled health professionals from the country and to Transfers furnish new insights on the recruitment patterns of skilled health per- Urban 16 14 7 7 17 12 20 9 15 3 3 sonnel. The objectives of the paper are twofold: and Rural Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Transfers ment of skilled professionals from South Africa in the health The type of transfer, whether rural or urban, was related to the fre- sector. The paper draws upon a detailed analysis of recruitment quency with which urban households receive food. Households receive advertising appearing in the South African Medical Journal for food transfers far more often when the food comes from an urban area. the period 2000-2004 and a series of interviews conducted with Around a quarter of households who had received food from other urban private recruiting enterprises. areas did so at least once a week (compared to only 5% of households Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< who received rural-urban transfers). Some 76% of households received key stakeholders in the South African health sector, the paper urban-urban transfers at least once every 2 months, compared to only offers a series of recommendations for addressing the problem of 40% of households receiving rural-urban transfers (Figure 13). This might skilled health migration. These recommendations are grounded suggest that urban-urban networks and support mechanisms are stronger in both South African experience and an interrogation of inter- than rural-urban ties. Alternatively, transportation is undoubtedly easier national debates and ‘good policy’ practice for regulating recruit- between urban areas and urban-urban transfers are also much less likely ment. to be affected by the seasonal agricultural cycle. The paper is organized into five sections. Section Two positions Transfers from rural and other urban areas are both dominated by debates about the migration of skilled health professionals within a cereals. All urban households in the study cities received cereals at some wider literature that discusses the international mobility of talent. point during the year, irrespective of the source. However, there was a Section Three reviews research on the global circulation of health pro- marked difference in the frequency of transfers with a quarter of urban- fessionals, focusing in particular upon debates relating to the experience sourced cereals arriving at least once a week and 80% arriving at least of countries in the developing world. Section Four moves the focus from once every couple of months or more frequently (Table 13). In contrast, international to South African issues and provides new empirical mate- cereals from rural areas came far less frequently, a clear reflection of the rial drawn from the survey of recruitment patterns and key interviews rural agricultural cycle. Those receiving cereals from other urban areas undertaken with health sector recruiters operating in South Africa. are not dependent on the cycle since the cereals can be purchased and Section Five addresses the questions of changing policy interventions in sent at any time of the year. South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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Figure 13: Frequency of Food Transfers to Urban Households by Area of Origin (% of XECUTIVE UMMARY Households)E S 60 ealth workers are one of the categories of skilled professionals most 51 affected by globalization. Over the past decade, 50 there has emerged a substantial body of research that tracks patterns of international migration of health personnel, 40 H 35 assesses causes and consequences, and debates policy responses at global 31 30 and national scales. Within this literature, the case of South 27 Africa is 25attracting growing interest. For almost 15 years South Africa has been 20 the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the 14 consequences of the resultant out- 10 8 flow of5 health professionals is a core policy issue for the national government. 0 At leastThis once paper aimsAt least to to examine 3–6policy times debates a andAt issues least once concerning a week once every 2 year a year the migration ofmonths skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health personnel. The Urbanobjectives of the paperRural are twofold: Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Table 13: Frequencyment of Transfers of skilled by Areaprofessionals of Origin (% from of Households South Africa in Previous in the 12 health Months) sector. The paper draws upon a detailed analysis of recruitment Food Type Frequencyadvertising appearing in theUrban South (%) African MedicalRural (%) Journal for Cereals At leastthe once period a week 2000-2004 and 27a series of interviews2 conducted with At leastprivate once every recruiting 2 months enterprises.52 25 3-6Q times 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< a year 12 36 At leastkey once stakeholders a year in the South9 African health37 sector, the paper Total offers a series of recommendations100 for addressing100 the problem of skilled health migration. These recommendations are grounded in both South African experience and an interrogation of inter- Other differences between rural and urban transfers also emerged. national debates and ‘good policy’ practice for regulating recruit- Households receiving urban transfers were more likely to receive almost ment. all types of foodstuffs (with the exception of foods made from beans, The paper is organized into five sections. Section Two positions peas, lentils or nuts). For example, 51% of households receiving urban- debates about the migration of skilled health professionals within a urban transfers received vegetables compared with 35% of those receiving wider literature that discusses the international mobility of talent. rural-urban transfers. Or again, 39% of urban-urban transfer households Section Three reviews research on the global circulation of health pro- received meat or poultry compared with only 23% of rural-urban transfer fessionals, focusing in particular upon debates relating to the experience households. The differences were particularly marked when it comes to of countries in the developing world. Section Four moves the focus from processed foods such as sugar/honey (40% versus 5%) and foods made international to South African issues and provides new empirical mate- with oil, fat or butter (33% versus 6%). rial drawn from the survey of recruitment patterns and key interviews Food transfers are particularly important for food-insecure urban undertaken with health sector recruiters operating in South Africa. households. Of the 1,809 households receiving food transfers from out- Section Five addresses the questions of changing policy interventions in side the city, 84% were food insecure and 16% were food secure. The South Africa towards the outflow of skilled health professionals and the relative importance of food transfers for food insecure households holds recruitment of foreign health professionals to work in South Africa. The whether the food is received from rural areas or other urban areas. There were, however, variations between cities. In Gaborone, for example,

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EXECUTIVE SUMMARY households were more likely to be food-secure if they receive food from rural sources (33%), compared to either urban only (7%) or combined ealth workers are one of the categories of skilled profession- urban and rural sources (8%). In Maputo, on the other hand, only 1% of als most affected by globalization. Over the past decade, food-secure households received food from rural areas only, with 17% of there has emerged a substantial body of research that tracks food-secure households getting food from urban areas only (mostly from patterns of international migration of health personnel, migrants in South African cities) and the rest from both sources. Around H 80% of households receiving food transfers said that they were important assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is or very important to the household while 9% said they were critical to attracting growing interest. For almost 15 years South Africa has been household survival.74 Almost the same number (77%) said that the food the target of a ‘global raiding’ of skilled professionals by several devel- was sent to help the urban household feed itself. Only 20% said the food oped countries. How to deal with the consequences of the resultant out- was sent as a gift. The centrality of food transfers to urban food con- flow of health professionals is a core policy issue for the national gov- sumption was illustrated by the fact that only 3% of households receiving ernment. food sold it for cash income. The rest consumed the food themselves.75 This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to Table 14: Types of Food Transferred furnish new insights on the recruitment patterns of skilled health per- Rural-Urban % of Urban-Urban % of sonnel. The objectives of the paper are twofold: Receiving Households Receiving Households Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Cereals/grain 100 100 ment of skilled professionals from South Africa in the health Roots/tubers 21 35 sector. The paper draws upon a detailed analysis of recruitment Vegetables 37 51 advertising appearing in the South African Medical Journal for Fruit 9 19 the period 2000-2004 and a series of interviews conducted with Meat/poultry 23 39 private recruiting enterprises. Eggs 4 14 Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Food from beans, peas, lentils, nuts 40 30 key stakeholders in the South African health sector, the paper Cheese/milk products 10 18 offers a series of recommendations for addressing the problem of Foods made with oil, fat, butter 6 33 skilled health migration. These recommendations are grounded Sugar/honey 5 40 in both South African experience and an interrogation of inter- N 753 890 national debates and ‘good policy’ practice for regulating recruitment. The paper is organized into five sections. Section Two positions As noted above, food transfers from households outside the city to debates about the migration of skilled health professionals within a households within it are a notable feature in a number of SADC cities. wider literature that discusses the international mobility of talent. The final question which the AFSUN data sheds light on is whether Section Three reviews research on the global circulation of health pro- migrant households are more or less likely to receive transfers than non- fessionals, focusing in particular upon debates relating to the experience migrant households. Frayne has argued that migrants in the city receive of countries in the developing world. Section Four moves the focus from such transfers to keep them going while they search for work or other international to South African issues and provides new empirical mate- sources of income. This suggests that migrant households, with their rial drawn from the survey of recruitment patterns and key interviews stronger rural ties, would be more likely to receive food from rural house- undertaken with health sector recruiters operating in South Africa. holds. And so it proved although the difference was not that large. A Section Five addresses the questions of changing policy interventions in total of 15% of migrant households received food transfers from rural rel- South Africa towards the outflow of skilled health professionals and the atives, compared with only 10% of non-migrant households. Some non- recruitment of foreign health professionals to work in South Africa. The migrant households clearly maintain links with rural areas of sufficient strength to facilitate food transfers. On the other hand, non-migrant

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EXECUTIVEhouseholdsSUMMARY were more likely than migrant households to received food transfers from other urban areas (14% versus 10%). In addition, 61% of those non-migrantealth workers households are one receiving of the categoriesfood transfers of skilled got them profession- from relatives in otherals most urban affected areas by (compared globalization. with Overonly 28% the pastwho decade,got them from rural areas).there hasMigrant emerged households a substantial were alsobody more of research likely to that receive tracks urban than patternsrural transfers of international although the migration difference of healthwas not personnel, as great (46% Hversus 43% of the total). assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is Table 15: Typesattracting of Transfer growing as Household interest. Migrant-StatusFor almost 15 years South Africa has been the target of a ‘globalMigrant raiding’ Households of skilled professionalsNon-Migrant Householdsby several developed countries. How to deal(%) with the consequences(%) of the resultant out- Rural-Urbanflow Food of Transfers health professionals43 is a core policy issue for28 the national gov- Urban-Urbanernment. Food Transfers 46 61 Rural and UrbanThis Transfers paper aims to to examine11 policy debates and11 issues concerning the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns of skilled health per- concLusonnel.Sion The objectives of the paper are twofold: Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H mentigration of skilled within professionals and to the from Southern South AfricaAfrican in region the health has sector.changed The paper dramatically draws upon in recenta detailed decades. analysis All ofof recruitmentthe evidence advertisingsuggests appearing that the inregion the Southis undergoing African a Medical rapid urban Journal transi for- the periodtion through 2000-2004 internal and migrationa series of andinterviews natural conducted population with Mincrease. There has also been significant growth in temporary cross- private recruiting enterprises. borderQ movement 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< within the region. The implications of the region’s new mobilitykey regime stakeholders for food securityin the South in general African (and health urban sector, food security the paper in particular)offers need a series much of further recommendations exploration andfor addressinganalysis. To the what problem degree of is heightenedskilled mobility health related migration. to problems These recommendationsof food insecurity? areFood grounded security shocks andin both chronic South food African insecurity experience can certainly and an be interrogation major motives of forinter- migrationnational for income-generating debates and ‘good opportunities. policy’ practice War for and regulating conflict, particurecruit-- larly in Angolament. and the DRC, led to the displacement of millions who fledThe to neighbouring paper is organized countries. into Thefive sections.collapse of Section the Zimbabwean Two positions economy sincedebates 2000 about has thepushed migration hundreds of skilled of thousands health professionalsof desperate food-insecurewithin a peoplewider literature out of the that country. discusses The themeltdown international has affected mobility the of poor talent. but has alsoSection ravaged Three the reviews urban middle-classresearch on theleaving global migration circulation as the of healthmain “exit pro- option.”fessionals, Chronic focusing poverty in particular and related upon food debates insecurity relating is alsoto the partially experience responsibleof countries for in thethe upsurgedeveloping in post-1990 world. Section migration Four from moves countries the focus such from as Lesotho,international Mozambique, to South MalawiAfrican and issues Swaziland. and provides new empirical mate- rialCurrent drawn from conceptualisations the survey of recruitment of the food securitypatterns crisis and keyin Africa interviews provide anundertaken inadequate with basis health for working sector recruiters at the interface operating between in South migration Africa. and foodSection security. Five addressesFirst, there the is questionsthe pervasive of changing assumption policy that interventions food security in isSouth primarily Africa a ruraltowards problem the outflow that will of beskilled resolved health through professionals technical and inno the- vationrecruitment amongst of foreignsmallholders health (in professionals the guise of to a worknew Green in South Revolution). Africa. The What seems to be forgotten in this essentially romantic view of the

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EXECUTIVE SUMMARY African rural household is that its food security is not simply, or even mainly, a function of what it does or does not grow for itself. Up and ealth workers are one of the categories of skilled profession- down the continent rural households purchase some or most of their als most affected by globalization. Over the past decade, food and they do so with cash that they receive from household members there has emerged a substantial body of research that tracks who have migrated to earn income in other places within the country patterns of international migration of health personnel, and across borders. The evidence for Southern Africa, at least, is that H these rural households do not invest remittances in agriculture but in assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is basic necessities, including food purchase.76 Rural food security, in other attracting growing interest. For almost 15 years South Africa has been words, may be improved but will not be resolved by current productionist the target of a ‘global raiding’ of skilled professionals by several devel- approaches to food security. oped countries. How to deal with the consequences of the resultant out- A second flawed assumption is that food security in urban areas is flow of health professionals is a core policy issue for the national gov- about promoting urban agriculture. Urban agriculture can certainly con- ernment. tribute to the food security of some households but it is very far from This paper aims to to examine policy debates and issues concerning being a panacea for all.77 The obsession with urban agriculture may be the migration of skilled health professionals from the country and to well-intentioned but it derives from the misplaced idea that increased furnish new insights on the recruitment patterns of skilled health per- food production is the key to urban food security. The primary determi- sonnel. The objectives of the paper are twofold: nant of food insecurity in African cities is not production shortfalls but Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H the lack of access to food and that means the absence of a regular and ment of skilled professionals from South Africa in the health reliable income with which to purchase it. Even within the poorest areas sector. The paper draws upon a detailed analysis of recruitment of the city, access varies considerably from household to household with advertising appearing in the South African Medical Journal for wage employment, other income-generating activity, the size and struc- the period 2000-2004 and a series of interviews conducted with ture of the household, the educational level of the household members, private recruiting enterprises. access to social grants and being embedded in social networks. This Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< paper has also demonstrated that the migrant status of a household is a key stakeholders in the South African health sector, the paper key determinant of food security. The differences between migrant and offers a series of recommendations for addressing the problem of non-migrant households are relatively significant. While there are many skilled health migration. These recommendations are grounded poor and food insecure households in both camps, there are more food in both South African experience and an interrogation of inter- secure households in the non-migrant group. national debates and ‘good policy’ practice for regulating recruit- A third problematic assumption is that the rural and urban are sepa- ment. rate spheres with a deep divide between them. This dualistic view of the The paper is organized into five sections. Section Two positions world is clearly at odds with the observable web of connections and flows debates about the migration of skilled health professionals within a that bind rural and urban spaces together. The concept of the stretched wider literature that discusses the international mobility of talent. or multi-nodal household attempts to capture the reality that even at Section Three reviews research on the global circulation of health pro- the micro-scale, there is regular circulation of people, goods and money fessionals, focusing in particular upon debates relating to the experience between town and countryside. Conceptually and methodologically, this of countries in the developing world. Section Four moves the focus from reality means that it is impossible to fully explain the state of food secu- international to South African issues and provides new empirical mate- rity of urban households without reference to their rural counterparts, rial drawn from the survey of recruitment patterns and key interviews and vice-versa. For example, one of the reasons why there are fewer food undertaken with health sector recruiters operating in South Africa. secure migrant households in the cities may be because, unlike non- Section Five addresses the questions of changing policy interventions in migrant households, they remit a portion of their income to rural areas South Africa towards the outflow of skilled health professionals and the which are in even greater need of the cash. On the other hand, the situ- recruitment of foreign health professionals to work in South Africa. The ation of migrant households would be even more desperate but for relatively widespread intra-household rural-urban transfers of food.

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EXECUTIVETheSUMMARY fourth assumption is that migration and mobility are of limited relevance to food security. There are some recent signs of recognition of the reality thatealth migration workers andare oneremittances of the categories play an important of skilled roleprofession- in the food securityals strategies most affected of rural by households. globalization. What Over tends the pastto be decade, overlooked is the role ofthere migration has emerged in the fooda substantial security ofbody urban of researchhouseholds. that As tracks this paper shows,patterns the of majority international of households migration in ofpoor health areas personnel, in Southern HAfrican cities either consist entirely of migrants or a mix of migrants and assesses causes and consequences, and debates policy responses at global non-migrants.and national scales. Rapid Withinurbanization, this literature, increased the circulation case of South and growing Africa is cross-borderattracting growing migration interest. have Forall meantalmost that 15 yearsthe number South Africaof migrants has been and migrantthe target households of a ‘global in raiding’the city ofhas skilled grown professionals exponentially. by Thisseveral is likely devel- to continueoped countries. for several How more to deal decades with theas urbanization consequences continues. of the resultant We can -out- notflow simply of health assume professionals that all poor is a urbancore policy households issue for are the alike. national While gov- levels ofernment. food insecurity are unacceptably high amongst all of them, migrant householdsThis paper do aimshave toa greaterto examine chance policy of being debates food and insecure issues withconcerning all of its attendantthe migration health of skilledand nutritional health professionals problems. This from fact the needs country to be and recog to - nisedfurnish by new policy-makers insights on and the acted recruitment upon. patterns of skilled health personnel. The objectives of the paper are twofold: endnoteSQ +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H ment of skilled professionals from South Africa in the health 1 Global Commissionsector. Theon International paper draws Migration,upon a detailed Migration analysis in an of Interconnected recruitment World: New Directionsadvertising for appearing Action (Geneva, in the South2005); African UN General Medical Assembly, Journal for “Internationalthe Migration period 2000-2004 and Development. and a series Report of interviews of the Secretary-General” conducted with New York, 2006;private S. Castles recruiting and enterprises. R. Wise, eds., Migration and Development: PerspectivesQ from 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< the South (Geneva: IOM, 2008); UNDP, Overcoming Barriers: Human Mobilitykey and stakeholders Development in ,the Human South Development African health Report sector, 2009, the Newpaper York. offers a series of recommendations for addressing the problem of 2 J. Crush and skilledW. Pendleton, health migration.“Remitting These for Survival: recommendations Rethinking arethe grounded Developmentin Potential both South of Remittances African experience in Southern and Africa”an interrogation Global Development of inter- Studies 5(3-4)national (2009): debates1-28. and ‘good policy’ practice for regulating recruit- 3 B. Frayne andment. J. Crush, “Urban Food Insecurity and the New International Food SecurityThe paper Agenda” is organized Development into Southernfive sections. Africa Section 28(4) (2011):Two positions 527-44. 4 See http://www.agra-alliance.org/debates about the migration of skilled health professionals within a 5 A. Lernerwider and literature H. Eakin, that “An discusses Obsolete the Dichotomy?international Rethinking mobility of the talent. Rural- UrbanSection Interface Three in Terms reviews of Foodresearch Security on the and global Production circulation in the of Globalhealth pro- South”fessionals, Geographical focusing Journal in particular177(4) (2011): upon 311-20;debates seerelating also A.to theChampion experience and G. Hugo,of countries eds., New in Formsthe developing of Urbanization: world. BeyondSection the Four Rural-Urban moves the Dichotomy focus from (Aldershot:international Gower, to2004); South K. African Lynch, issuesRural-Urban and provides Interaction new inempirical the Developing mate- Worldrial (London: drawn fromRoutledge, the survey 2005). of recruitment patterns and key interviews 6 F. Ellisundertaken and N. Harris, with “Development health sector recruitersPatterns, operatingMobility and in SouthLivelihood Africa. Diversification”Section Five Keynote addresses Paper the for questions DFID Sustainable of changing Development policy interventions Retreat, in UniversitySouth of Africa Surrey, towards Guildford, the outflow2004, p. of 13. skilled health professionals and the 7 M. Tienda,recruitment E. Preston-Whyte, of foreign health S. Findley professionals and S. Tollman,to work ineds., South Africa Africa. on The the Move: African Migration and Urbanisation in Comparative Perspective

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EXECUTIVE SUMMARY (Johannesburg: Wits University Press, 2006); J. Crush and B. Frayne, eds., Surviving on the Move: Migration, Poverty and Development in Southern Africa ealth workers are one of the categories of skilled profession- (Cape Town and Midrand: SAMP and DBSA, 2010). als most affected by globalization. Over the past decade, 8 A. Zezza, C. Carletto, B. Davis and P. Winters, “Assessing the Impact of there has emerged a substantial body of research that tracks Migration on Food and Nutrition Security” Food Policy 36(1) (2011): 1–6; see patterns of international migration of health personnel, also T. Lacroix, “Migration, Rural Development, Poverty and Food Security: H A Comparative Perspective” International Migration Institute, Oxford assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is University, 2011. attracting growing interest. For almost 15 years South Africa has been 9 M. Ruel, J. Garrett and L. Haddad, “Rapid Urbanization and the Challenges the target of a ‘global raiding’ of skilled professionals by several devel- of Obtaining Food and Nutrition Security” In R. Semba and M. Bloem, eds., oped countries. How to deal with the consequences of the resultant out- Nutrition and Health in Developing Countries: 2nd Edition (New York: Humana flow of health professionals is a core policy issue for the national gov- Press, 2008), pp. 639-57. ernment. 10 UN-HABITAT, The State of African Cities 2010: Governance, Inequality and This paper aims to to examine policy debates and issues concerning Land Markets (Nairobi, 2010), p. 207. The UN-HABITAT data for Southern the migration of skilled health professionals from the country and to Africa includes the countries of Angola, Botswana, Lesotho, Mozambique, furnish new insights on the recruitment patterns of skilled health per- Namibia, South Africa, Swaziland, Zambia and Malawi but excludes other sonnel. The objectives of the paper are twofold: SADC countries such as the DRC, Malawi and Tanzania. Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H 11 K. Cox, D. Hemson and A. Todes, “Urbanization in South Africa and the ment of skilled professionals from South Africa in the health Changing Character of Migrant Labour in South Africa” South African sector. The paper draws upon a detailed analysis of recruitment Geographical Journal 86(1) (2004): 7-16. advertising appearing in the South African Medical Journal for 12 D. Posel and D. Casale, “Internal Migration and Household Poverty in Post- the period 2000-2004 and a series of interviews conducted with Apartheid South Africa” In R. Kanbur and H. Bhorat, eds., Poverty and Policy private recruiting enterprises. in Post-Apartheid South Africa (Pretoria: HSRC Press, 2006), pp. 351-65. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 13 P. Kok, M. O’Donovan, O. Bouare and J. Van Zyl, Internal Migration in South key stakeholders in the South African health sector, the paper Africa (Pretoria: HSRC Publishing, 2003); P. Kok and M. Collinson, Migration offers a series of recommendations for addressing the problem of and Urbanisation in South Africa (Pretoria: Statistics South Africa, 2006). skilled health migration. These recommendations are grounded 14 South African Cities Network, State of the Cities Report 2006 (Johannesburg, in both South African experience and an interrogation of inter- 2006), p. 2.18. national debates and ‘good policy’ practice for regulating recruit- 15 D. Posel and D. Casale, “What Has Been Happening to Internal Labour ment. Migration in South Africa, 1993-1999” South African Journal of Economics The paper is organized into five sections. Section Two positions 71(3) (2003): 455-79; D. Posel, “Moving On: Patterns of Labour Migration in debates about the migration of skilled health professionals within a Post-Apartheid South Africa” In Tienda et al, Africa on the Move, pp. 217-31; wider literature that discusses the international mobility of talent. A. Todes, P. Kok, M. Wentzel, J. Van Zyl and C. Cross, “Contemporary South Section Three reviews research on the global circulation of health pro- African Urbanization Dynamics” Urban Forum 21(3) (2010): 331-48. fessionals, focusing in particular upon debates relating to the experience 16 M. Collinson, S. Tollman, K. Kahn, S. Clark and M. Garenne, “Highly of countries in the developing world. Section Four moves the focus from Prevalent Circular Migration: Households, Mobility and Economic Status international to South African issues and provides new empirical mate- in Rural South Africa” In Tienda et al, Africa on the Move, pp. 194-216; M. rial drawn from the survey of recruitment patterns and key interviews Collinson, “Striving Against Adversity: The Dynamics of Migration, Health undertaken with health sector recruiters operating in South Africa. and Poverty in Rural South Africa” Global Health Action 3 (2010). Section Five addresses the questions of changing policy interventions in 17 Posel and Casale, “Internal Labour Migration and Household Poverty in Post- South Africa towards the outflow of skilled health professionals and the Apartheid South Africa” pp. 352-3. recruitment of foreign health professionals to work in South Africa. The 18 D. Posel, “Households and Labour Migration in Post-Apartheid South Africa” Studies in Economics and Econometrics 34(3) (2010): 129-41.

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19EXECUTIVE J. Ferguson,S UMMARYExpectations of Modernity: Myths and Meanings of Urban Life on the Copperbelt (Berkeley: University of California Press, 1999). 20 D. Potts, “Counter-Urbanizationealth workers are on one the of Zambian the categories Copperbelt? of skilled Interpretations profession- and Implications”als Urban most Studiesaffected 42 by (2005): globalization. 538-609. Over the past decade, 21 Ibid., p. 598. there has emerged a substantial body of research that tracks 22 E. Ianchovichinapatterns and S. Lundstrom, of international “What migration Are the ofConstraints health personnel, to Inclusive GrowthH in Zambia?” World Bank Report, Washington, 2008. assesses causes and consequences, and debates policy responses at global 23 C. Mutambirwaand national and scales. D. Potts, Within “Changing this literature, Patterns the of Africancase of South Rural-Urban Africa is Migrationattracting and Urbanization growing interest. in Zimbabwe” For almost Eastern 15 years and South Southern Africa African has been Geographicalthe target Journal of a ‘global1(1) (1990): raiding’ 26-39. of skilled professionals by several devel- 24 D. Pottsoped and countries. C. Mutambirwa, How to deal“Rural-Urban with the consequencesLinkages in Contemporary of the resultant out- Harare:flow Why of health Migrants professionals Need Their is Land”a core Journalpolicy issue of Southern for the Africannational Studies gov- 16(4)ernment. (1990): 177-98. 25 D. Potts Thisand C. paper Mutambirwa, aims to to “’Basicsexamine are policy Now debates a Luxury’: and Perceptions issues concerning of Structuralthe migration Adjustment’s of skilled Impact health on Rural professionals and Urban from Areas the incountry Zimbabwe” and to Environmentfurnish andnew Urbanization insights on the10(1) recruitment (1998): 55-76; patterns D. Potts,”of skilled Urban health per- Unemploymentsonnel. The and objectives Migrants of in the Africa: paper Evidence are twofold: from Harare 1985–1994” DevelopmentQ and +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Change 31(4) (2000): 879–910. 26 D. Potts, “‘Allment My Hopes of skilled and professionals Dreams are Shattered:’from South Urbanization Africa in the and health Migrancy in ansector. Imploding The paper Economy draws – upon The Casea detailed of Zimbabwe” analysis of Geoforum recruitment 37(4) (2006):advertising 536-51; D. appearing Potts, “Internal in the MigrationSouth African in Zimbabwe: Medical JournalThe Impact for of Livelihoodthe Destruction period 2000-2004 in Rural andand Urbana series Areas” of interviews In Crush conducted and Tevera, with Zimbabwe’s Exodusprivate, pp. recruiting 79-111. enterprises. 27 Potts, “InternalQ 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Migration in Zimbabwe” p. 101. 28 D. Potts, “‘Restoringkey stakeholders Order?’ The in the Interrelationships South African Betweenhealth sector, Operation the paper Murambatsvinaoffers in Zimbabwea series of recommendationsand Urban Poverty, for Informal addressing Housing the problem and of Employment”skilled Journal health of Southern migration. African These Studies recommendations 32(2) (2006): 273-91; are grounded D. Potts, “Cityin Lifeboth in South Zimbabwe African at aexperience Time of Fear and and an Loathing:interrogation Urban of inter- Planning, Urbannational Poverty, debates and Operationand ‘good policy’Murambatsvina” practice for In regulating M. Murray recruit- and G. Myers, eds.,ment. Cities in Contemporary Africa (New York: Palgrave Macmillan, 2007), pp.The 265-88; paper M.is organized Vambe, ed., into The five Hidden sections. Dimensions Section ofTwo Operation positions Murambatsvinadebates about (Harare: the migration Weaver Press, of skilled 2008). health professionals within a 29 Crushwider and Tevera,literature Zimbabwe’s that discusses Exodus the. international mobility of talent. 30 D. Potts,Section Circular Three Migration reviews in research Zimbabwe on &the Contemporary global circulation Sub-Saharan of health Africa pro- (Woodbridge:fessionals, James focusing Currey, in particular 2010). upon debates relating to the experience 31 Ibid., ofp. countries29. in the developing world. Section Four moves the focus from 32 Ibid., internationalp. 193; D. Potts, to South“Urban African Growth issues and Urbanand provides Economies new empiricalin Eastern mate- and Southernrial drawnAfrica: from Trends the and survey Prospects” of recruitment In D. Bryceson patterns and and D. key Potts, interviews eds., Africanundertaken Urban Economies: with health Viability, sector Vitality recruiters or Vitiation? operating (Basingstoke: in South Africa. Palgrave Macmillan,Section 2006), Five addressespp. 67-106; the D. questions Potts, “Recent of changing Trends policy in Rural-Urban interventions and in Urban-RuralSouth Africa Migration towards in Sub-Saharan the outflow ofAfrica: skilled The health Empirical professionals Evidence and and the Implicationsrecruitment for Understanding of foreign health Livelihood professionals Insecurity” to work Working in South Paper Africa. No. The6, Department of Geography, King’s College, London, 2008.

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EXECUTIVE SUMMARY 33 B. Frayne, W. Pendleton, J. Crush, B. Acquah, J. Battersby-Lennard, E. Bras, A. Chiweza, T. Dlamini, R. Fincham, F. Kroll, C. Leduka, A. Mosha, C. ealth workers are one of the categories of skilled profession- Mulenga, P. Mvula, A. Pomuti, I. Raimundo, M. Rudolph, S. Ruysenaa, N. als most affected by globalization. Over the past decade, Simelane, D. Tevera, M. Tsoka, G. Tawodzera and L. Zanamwe, The State of there has emerged a substantial body of research that tracks Urban Food Insecurity in Southern Africa, AFSUN Series No. 2, Cape Town, patterns of international migration of health personnel, 2010. H 34 Zezza et al., “Assessing the Impact of Migration” p. 2. assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is 35 R. Vargas-Lundius, G. Lanly, M. Villarreal and M. Osorio, International attracting growing interest. For almost 15 years South Africa has been Migration, Remittances and Rural Development (Rome: FAO and IFAD, 2008). the target of a ‘global raiding’ of skilled professionals by several devel- 36 V. Hosegood and I. Timæus, “Household Composition and Dynamics in oped countries. How to deal with the consequences of the resultant out- Kwazulu Natal, South Africa: Mirroring Social Reality in Longitudinal Data flow of health professionals is a core policy issue for the national gov- Collection” In E. Van der Walle, ed., African Households: Census Data, (New ernment. York: M.E. Sharpe, 2005), pp. 58-77. This paper aims to to examine policy debates and issues concerning 37 Ibid., p. 10. the migration of skilled health professionals from the country and to 38 C. Tacoli, “The Links Between Urban and Rural Development” Environment furnish new insights on the recruitment patterns of skilled health per- and Urbanization 15(1) (2003), p. 3. sonnel. The objectives of the paper are twofold: 39 W. Pendleton and B. Frayne, “Migration in Namibia: Combining Macro and Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Micro Approaches to Research Design and Analysis” International Migration ment of skilled professionals from South Africa in the health Review 35(4) (2001): 1054-85. sector. The paper draws upon a detailed analysis of recruitment 40 A. du Toit and D. Neves, “Informal Social Protection in Post-Apartheid advertising appearing in the South African Medical Journal for Migrant Networks: Vulnerability, Social Networks and Reciprocal Exchange the period 2000-2004 and a series of interviews conducted with in the Eastern and Western Cape, South Africa” Working Paper No. 2, private recruiting enterprises. Programme for Land and Agrarian Studies (PLAAS), University of Western Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Cape, Bellville, 2009, pp. 19-20; see also S. Bekker, “Diminishing Returns: key stakeholders in the South African health sector, the paper Circulatory Migration Linking Cape Town to the Eastern Cape” South African offers a series of recommendations for addressing the problem of Journal of Demography 8(1) (2001): 1-8; L. Bank and G. Minkley, “Going skilled health migration. These recommendations are grounded Nowhere Slowly? Land, Livelihoods and Rural Development in the Eastern in both South African experience and an interrogation of inter- Cape” Social Dynamics 31(1) (2005): 1-38; A. du Toit and D. Neves, “In national debates and ‘good policy’ practice for regulating recruit- Search of South Africa’s ‘Second Economy’: Chronic Poverty, Economic ment. Marginalisation and Adverse Incorporation in Mt Frere and Khayelitsha” The paper is organized into five sections. Section Two positions Working Paper No 1, Programme for Land and Agrarian Studies (PLAAS), debates about the migration of skilled health professionals within a University of Western Cape, Bellville, 2007; and A. du Toit and D. Neves, wider literature that discusses the international mobility of talent. “Trading on a Grant: Integrating Formal and Informal Social Protection in Section Three reviews research on the global circulation of health pro- Post-apartheid Migrant Networks” Working Paper No. 3, Programme for Land fessionals, focusing in particular upon debates relating to the experience and Agrarian Studies (PLAAS), University of Western Cape, Bellville, 2009. of countries in the developing world. Section Four moves the focus from 41 du Toit and Neves, “Informal Social Protection in Post-Apartheid Migrant international to South African issues and provides new empirical mate- Networks, pp. 39-40. rial drawn from the survey of recruitment patterns and key interviews 42 J. Grest, “Urban Governance, State Capacity and the Informalization of Urban undertaken with health sector recruiters operating in South Africa. Management in Maputo: Some Thoughts on Poverty, Informalization and Section Five addresses the questions of changing policy interventions in Survival in the City” Paper presented at Regional Workshop on South African South Africa towards the outflow of skilled health professionals and the Cities, Stellenbosch, 2006. recruitment of foreign health professionals to work in South Africa. The 43 J. Crush, B. Dodson, J. Gay, T. Green and C. Leduka, Migration, Remittances and ‘Development’ in Lesotho, SAMP Migration Policy Series No. 52, Cape Town, 2010, p. 12. 1 46 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MMIGRATIONigration PPOLICYolicy SERIESerieS NnOo. 4560

44EXECUTIVE J. Crush, A.S UMMARYJeeves and D. Yudelman, South Africa’s Labor Empire (Boulder: Westview Press, 1991). 45 J. Ward and P. Fleming.ealth workers “Change are in one Body of Weightthe categories and Body of skilledComparison profession- in African Mine Recruits”als most Ergonomics affected by 7(1) globalization. (1964): 83-90. Over the past decade, 46 J. Crush and V. Williams,there has Labour emerged Migration a substantial Trends body and Policiesof research in Southern that tracks Africa, SAMP Policypatterns Brief of No. international 23, Cape Town, migration 2010. of health personnel, 47 CrushH and Tevera, Zimbabwe’s Exodus, p. 13 assesses causes and consequences, and debates policy responses at global 48 Crushand et al.,national Migration, scales. Remittances Within this and literature, ‘Development’ the casein Lesotho of South. Africa is 49 T. Ulikiattracting and J. Crush, growing “Poverty, interest. Gender For almost and Migrancy: 15 years South Lesotho’s Africa Migrant has been Farmworkersthe target in ofSouth a ‘global Africa” raiding’ Development of skilled Southern professionals Africa 24(1)by several (2007): devel- 155-72;oped L. countries.Griffin, “Unravelling How to deal Rights: with the‘Illegal’ consequences Migrant Domestic of the resultant Workers out- in Southflow Africa” of health Southern professionals African Review is a core of Sociology policy issue 42(2) for (2011): the national 83-101. gov- 50 W. Pendleton,ernment. J. Crush, E. Campbell, T. Green, H. Simelane, D. Tevera and F. De Vletter,This Migration, paper aims Remittances to to examine and Development policy debates in Southern and issues Africa concerning, SAMP Migrationthe migration Policy Series of skilled No. 44, health Cape professionals Town, 2006. from the country and to 51 Crushfurnish and Tevera, new insights Zimbabwe’s on the Exodus recruitment, p. 9. patterns of skilled health per- 52 J. Crush,sonnel. A. Chikanda The objectives and G. of Tawodzera, the paper areThe twofold: Third Wave: Mixed Migration from ZimbabweQ +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H to South Africa, SAMP Migration Policy Series No. 59, Cape Town, 2012. ment of skilled professionals from South Africa in the health 53 B. Rutherford,sector. “An UnsettledThe paper Belonging: draws upon Zimbabwean a detailed analysis Farm Workers of recruitment in Northern Southadvertising Africa” Journalappearing of Contemporary in the South African Studies Medical 26(4) Journal (2008): for 401-15; T. Ulickithe periodand J. Crush,2000-2004 “Poverty, and a Gender series of and interviews Migrancy: conducted Lesotho’s with Migrant Farmworkersprivate recruiting in South enterprises.Africa” In Crush and Frayne, Surviving on the Move, pp.Q 164-82; 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< N. Dinat and S. Peberdy, “Worlds of Work, Health and Migration: Domestickey stakeholders Workers in Johannesburg”the South African In Crush health and sector, Frayne, the Survivingpaper on the Move, pp.offers 215-34; a series T. ofAraia, recommendations S. Kola and T. for Polzer addressing Ngwato, the “Migration problem of and Employmentskilled in healththe Construction migration. Industry”These recommendations ACMS Research are Report, grounded Wits University,in both Johannesburg, South African 2010; experience J. Vearey, E.and Oliveira, an interrogation T. Madzimure of inter- and B. Ntini, “Workingnational the debates City: Experiences and ‘good policy’ of Migrant practice Women for regulating in Inner-City recruit- Johannesburg”ment. Southern Africa Media and Diversity Journal 9 (2011): 228-33. 54 R. Amit,The “Lost paper in the is organizedVortex: Irregularities into five sections. in the Detention Section Two and positions Deportation of Non-Nationalsdebates about in the South migration Africa” of FMSP skilled Research health professionalsReport, Wits withinUniversity, a Johannesburg,wider literature 2010; R.that Sutton discusses and theD. Vigneswaran, international “A mobility Kafkaesque of talent. State: DeportationSection and Three Detention reviews inresearch South Africa”on the globalCitizenship circulation Studies of15(5) health (2011): pro- 627-42.fessionals, focusing in particular upon debates relating to the experience 55 D. Vigneswaran,of countries “A in Footthe developing in the Door: world. Access Section to Asylum Four inmoves South the Africa” focus from Refugeinternational 25(2) (2009): to 41-52. South African issues and provides new empirical mate- 56 D. Vigneswaran,rial drawn from “The the Revolving survey of Door: recruitment Asylum patternsSeekers, andAccess key andinterviews Employmentundertaken in South with Africa”health sectorIn S. Gallo-Mosala, recruiters operating ed., Migrants’ in South Experiences Africa. WithinSection the South Five African addresses Labour the Market questions (Cape of changing Town: Scalabrini policy interventions Centre, 2009). in 57 T. Dalton-Greyling,South Africa towards “Refugees the and outflow Forced of Migrantsskilled health in South professionals Africa’s Urban and the Areas:recruitment Definitions, of Rights, foreign Levels health of professionals Wellbeing and to workPolicy” in TIPS South Annual Africa. The Forum, Johannesburg, 2008.

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EXECUTIVE SUMMARY 58 J. Fetzer, Public Attitudes Toward Immigration in the United States, France, and Germany (Cambridge: Cambridge University Press, 2000); J. Roemer, W. ealth workers are one of the categories of skilled profession- Lee and K. Van der Straeten, Racism, Xenophobia, and Distribution: Multi- als most affected by globalization. Over the past decade, Issue Politics in Advanced Democracies (Cambridge: Harvard University Press, there has emerged a substantial body of research that tracks 2007); R. Taras, Europe Old and New: Transnationalism, Belonging, Xenophobia patterns of international migration of health personnel, (Lanham MD: Rowman & Littlefield, 2009). H 59 J. Crush and S. Ramachandran, “Xenophobia, International Migration and assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is Development” Journal of Human Development and Capabilities 11(2) (2010): attracting growing interest. For almost 15 years South Africa has been 209-28. the target of a ‘global raiding’ of skilled professionals by several devel- 60 J. Crush, D. McDonald, V. Williams, K. Lefko-Everett, D. Dorey, D. Taylor oped countries. How to deal with the consequences of the resultant out- and R. la Sablonniere, The Perfect Storm: The Realities of Xenophobia in flow of health professionals is a core policy issue for the national gov- Contemporary South Africa, SAMP Migration Policy Series No 50, Cape Town, ernment. 2008; D. Everett, “Xenophobia, State and Society in South Africa, 2008-2010” This paper aims to to examine policy debates and issues concerning Politikon 38(1) (2011): 7-36. the migration of skilled health professionals from the country and to 61 Ibid. furnish new insights on the recruitment patterns of skilled health per- 62 Crush et al., Migration, Remittances and ‘Development’ in Lesotho. sonnel. The objectives of the paper are twofold: 63 Pendleton et al., Migration, Remittances and Development in Southern Africa; F. Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H de Vletter, “Migration and Development in Mozambique: Poverty, Inequality ment of skilled professionals from South Africa in the health and Survival” Development Southern Africa 24(1) (2007): 137-54; B. Dodson, sector. The paper draws upon a detailed analysis of recruitment Gender, Migration and Remittances in Southern Africa, SAMP Migration Policy advertising appearing in the South African Medical Journal for Series No. 49, Cape Town, 2008. the period 2000-2004 and a series of interviews conducted with 64 J. Vearey, L. Núñez and I. Palmary, “HIV, Migration and Urban Food Security: private recruiting enterprises. Exploring the Linkages” Report for RENEWAL Forced Migration Studies Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< Programmes, Wits University, Johannesburg 2009; D. Ashton, J. Mushaandja key stakeholders in the South African health sector, the paper and A. Pomuti, “The Inter-Relationships and Linkages among Migration, offers a series of recommendations for addressing the problem of Food Security and HIV/AIDS in Windhoek, Namibia” Report for RENEWAL, skilled health migration. These recommendations are grounded University of Namibia, Windhoek, 2009. in both South African experience and an interrogation of inter- 65 Frayne et al, The State of Urban Food Insecurity in Southern Africa, p. 28. national debates and ‘good policy’ practice for regulating recruit- 66 C. Tacoli, “Rural-Urban Interactions: A Guide to the Literature” Environment ment. and Urbanization 10(1) (1998): 147-66. The paper is organized into five sections. Section Two positions 67 B. Frayne, “Survival of the Poorest: Food Security and Migration in Namibia” debates about the migration of skilled health professionals within a PhD Thesis, Queen’s University, 2001; B. Frayne, “Survival of the Poorest: wider literature that discusses the international mobility of talent. Migration and Food Security in Namibia” In Mougeot, Agropolis, pp. 31-50; B. Section Three reviews research on the global circulation of health pro- Frayne, “Migration and the Changing Social Economy of Windhoek, Namibia” fessionals, focusing in particular upon debates relating to the experience Development Southern Africa 24(1) (2007): 91-108. of countries in the developing world. Section Four moves the focus from 68 Frayne, “Survival of the Poorest”, p. 278. international to South African issues and provides new empirical mate- 69 M. Paulo, C. Rosário and I. Tvedten, “Xiculongo: Social Relations of Urban rial drawn from the survey of recruitment patterns and key interviews Poverty in Maputo, Mozambique” Report No. 13, Chr. Michelsen Institute, undertaken with health sector recruiters operating in South Africa. Bergen, Norway, 2007, p. 54. Section Five addresses the questions of changing policy interventions in 70 Potts, Circular Migration in Zimbabwe. South Africa towards the outflow of skilled health professionals and the 71 G. Tawodzera, “Vulnerability and Resilience in Crisis: Urban Household Food recruitment of foreign health professionals to work in South Africa. The Insecurity in Harare, Zimbabwe” PhD Thesis, University of Cape Town, 2010. 72 For other examples see W. Smit, “The Rural Linkages of Urban Households in

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EXECUTIVEDurban, SouthSUMMARY Africa” Environment and Urbanization 10(1) (1998): 77-87; F. Kruger, “Taking Advantage of Rural Assets as a Coping Strategy for the Urban Poor: The Case ofealth Rural-Urban workers are Interrelations one of the categoriesin Botswana” of skilled Environment profession- and Urbanization 10(1)als (1998): most affected 119-34; by J. globalization.Andersson, “Reinterpreting Over the past thedecade, Rural- Urban Connection:there Migration has emerged Practices a substantial and Socio-Cultural body of research Dispositions that tracks of Buhera Workers inpatterns Harare” of Africainternational 71(1) (2001): migration 82-112. of health personnel, 73 FrayneH et al, The State of Urban Food Insecurity in Southern Africa. assesses causes and consequences, and debates policy responses at global 74 Ibid., andp. 45. national scales. Within this literature, the case of South Africa is 75 Ibid., attractingp. 46. growing interest. For almost 15 years South Africa has been 76 Crushthe and target Pendleton, of a ‘global “Remitting raiding’ for of Survival.” skilled professionals by several devel- 77 J. Crush,oped A. countries. Hovorka Howand D.to Tevera,deal with “Food the consequencesSecurity in Southern of the resultantAfrican out- Cities:flow The of Place health of professionalsUrban Agriculture” is a core Progress policy inissue Development for the national Studies gov- 11(2011):ernment. 285-305. This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to Migrationfurnish p onewLicy insights Serie onS the recruitment patterns of skilled health personnel. The objectives of the paper are twofold: 1. Covert Operations:Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H Clandestine Migration, Temporary Work and Immigration Policy in Southment Africa of skilled (1997) professionals ISBN 1-874864-51-9 from South Africa in the health 2. Riding the Tiger:sector. Lesotho The paper Miners draws and upon Permanent a detailed Residence analysis in of South recruitment Africa (1997) ISBNadvertising 1-874864-52-7 appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with 3. International Migration, Immigrant Entrepreneurs and South Africa’s Small private recruiting enterprises. Enterprise Economy (1997) ISBN 1-874864-62-4 Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 4. Silenced by Nationkey stakeholders Building: African in the SouthImmigrants African and health Language sector, Policy the paperin the New South Africaoffers (1998)a series ISBN of recommendations 1-874864-64-0 for addressing the problem of 5. Left Out in theskilled Cold? health Housing migration. and Immigration These recommendations in the New South are Africagrounded (1998) ISBN in1-874864-68-3 both South African experience and an interrogation of inter- 6. Trading Places:national Cross-Border debates Traders and ‘good and policy’ the South practice African for regulatingInformal Sector recruit- (1998) ISBN ment.1-874864-71-3 7. ChallengingThe Xenophobia:paper is organized Myth intoand Realitiesfive sections. about Section Cross-Border Two positions Migration in Southerndebates Africa about (1998) the migrationISBN 1-874864-70-5 of skilled health professionals within a wider literature that discusses the international mobility of talent. 8. Sons Sectionof Mozambique: Three reviews Mozambican research Miners on the and global Post-Apartheid circulation Southof health Africa pro- (1998)fessionals, ISBN 1-874864-78-0 focusing in particular upon debates relating to the experience 9. Womenof countrieson the Move: in the Gender developing and Cross-Border world. Section Migration Four moves to South the focus Africa from (1998)international ISBN 1-874864-82-9. to South African issues and provides new empirical mate- 10. Namibiansrial drawn on South from Africa:the survey Attitudes of recruitment Towards Cross-Borderpatterns and keyMigration interviews and Immigrationundertaken Policy with (1998) health ISBN sector 1-874864-84-5. recruiters operating in South Africa. 11. BuildingSection Skills: Five Cross-Border addresses the Migrants questions and of the changing South African policy interventionsConstruction in IndustrySouth (1999) Africa ISBN towards 1-874864-84-5 the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The 12. Immigration & Education: International Students at South African Universities and Technikons (1999) ISBN 1-874864-89-6

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EXECUTIVE SUMMARY 13. The Lives and Times of African Immigrants in Post-Apartheid South Africa (1999) ISBN 1-874864-91-8 ealth workers are one of the categories of skilled profession- 14. Still Waiting for the Barbarians: South African Attitudes to Immigrants and als most affected by globalization. Over the past decade, Immigration (1999) ISBN 1-874864-91-8 there has emerged a substantial body of research that tracks 15. Undermining Labour: Migrancy and Sub-contracting in the South African Hpatterns of international migration of health personnel, Gold Mining Industry (1999) ISBN 1-874864-91-8 assesses causes and consequences, and debates policy responses at global 16. Borderline Farming: Foreign Migrants in South African Commercial and national scales. Within this literature, the case of South Africa is Agriculture (2000) ISBN 1-874864-97-7 attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- 17. Writing Xenophobia: Immigration and the Press in Post-Apartheid South oped countries. How to deal with the consequences of the resultant out- Africa (2000) ISBN 1-919798-01-3 flow of health professionals is a core policy issue for the national gov- 18. Losing Our Minds: Skills Migration and the South African Brain Drain (2000) ernment. ISBN 1-919798-03-x This paper aims to to examine policy debates and issues concerning 19. Botswana: Migration Perspectives and Prospects (2000) ISBN 1-919798-04-8 the migration of skilled health professionals from the country and to 20. The Brain Gain: Skilled Migrants and Immigration Policy in Post-Apartheid furnish new insights on the recruitment patterns of skilled health per- South Africa (2000) ISBN 1-919798-14-5 sonnel. The objectives of the paper are twofold: Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H 21. Cross-Border Raiding and Community Conflict in the Lesotho-South African ment of skilled professionals from South Africa in the health Border Zone (2001) ISBN 1-919798-16-1 sector. The paper draws upon a detailed analysis of recruitment 22. Immigration, Xenophobia and Human Rights in South Africa (2001) advertising appearing in the South African Medical Journal for ISBN 1-919798-30-7 the period 2000-2004 and a series of interviews conducted with 23. Gender and the Brain Drain from South Africa (2001) ISBN 1-919798-35-8 private recruiting enterprises. 24. Spaces of Vulnerability: Migration and HIV/AIDS in South Africa (2002) Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< ISBN 1-919798-38-2 key stakeholders in the South African health sector, the paper 25. Zimbabweans Who Move: Perspectives on International Migration in offers a series of recommendations for addressing the problem of Zimbabwe (2002) ISBN 1-919798-40-4 skilled health migration. These recommendations are grounded in both South African experience and an interrogation of inter- 26. The Border Within: The Future of the Lesotho-South African International national debates and ‘good policy’ practice for regulating recruit- Boundary (2002) ISBN 1-919798-41-2 ment. 27. Mobile Namibia: Migration Trends and Attitudes (2002) ISBN 1-919798-44-7 The paper is organized into five sections. Section Two positions 28. Changing Attitudes to Immigration and Refugee Policy in Botswana (2003) debates about the migration of skilled health professionals within a ISBN 1-919798-47-1 wider literature that discusses the international mobility of talent. 29. The New Brain Drain from Zimbabwe (2003) ISBN 1-919798-48-X Section Three reviews research on the global circulation of health pro- 30. Regionalizing Xenophobia? Citizen Attitudes to Immigration and Refugee fessionals, focusing in particular upon debates relating to the experience Policy in Southern Africa (2004) ISBN 1-919798-53-6 of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical mate- 31. Migration, Sexuality and HIV/AIDS in Rural South Africa (2004) rial drawn from the survey of recruitment patterns and key interviews ISBN 1-919798-63-3 undertaken with health sector recruiters operating in South Africa. 32. Swaziland Moves: Perceptions and Patterns of Modern Migration (2004) Section Five addresses the questions of changing policy interventions in ISBN 1-919798-67-6 South Africa towards the outflow of skilled health professionals and the 33. HIV/AIDS and Children’s Migration in Southern Africa (2004) recruitment of foreign health professionals to work in South Africa. The ISBN 1-919798-70-6

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34.EXECUTIVE Medical Leave:SUMMARY The Exodus of Health Professionals from Zimbabwe (2005) ISBN 1-919798-74-9 35. Degrees of Uncertainty:ealth workers Students are and one the of theBrain categories Drain in of Southern skilled profession- Africa (2005) ISBN 1-919798-84-6als most affected by globalization. Over the past decade, 36. Restless Minds: Souththere hasAfrican emerged Students a substantial and the Brainbody ofDrain research (2005) that tracks ISBNH 1-919798-82-Xpatterns of international migration of health personnel, assesses causes and consequences, and debates policy responses at global 37. Understanding Press Coverage of Cross-Border Migration in Southern Africa and national scales. Within this literature, the case of South Africa is since 2000 (2005) ISBN 1-919798-91-9 attracting growing interest. For almost 15 years South Africa has been 38. Northernthe target Gateway: of a Cross-Border‘global raiding’ Migration of skilled Between professionals Namibia by several and Angola devel- (2005)oped ISBN countries. 1-919798-92-7 How to deal with the consequences of the resultant out- 39. Early flowDepartures: of health The professionals Emigration is Potential a core policy of Zimbabwean issue for the Students national (2005) gov- ISBNernment. 1-919798-99-4 40. MigrationThis and paper Domestic aims Workers:to to examine Worlds policy of Work, debates Health and andissues Mobility concerning in Johannesburgthe migration (2005) of ISBN skilled 1-920118-02-0 health professionals from the country and to 41. The Qualityfurnish ofnew Migration insights Serviceson the recruitment Delivery in patternsSouth Africa of skilled (2005) health per- ISBNsonnel. 1-920118-03-9 The objectives of the paper are twofold: Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H 42. States of Vulnerability: The Future Brain Drain of Talent to South Africa ment of skilled professionals from South Africa in the health (2006) ISBN 1-920118-07-1 sector. The paper draws upon a detailed analysis of recruitment 43. Migration andadvertising Development appearing in Mozambique: in the South Poverty, African Inequality Medical and Journal Survival for (2006) ISBN the1-920118-10-1 period 2000-2004 and a series of interviews conducted with 44. Migration, Remittancesprivate recruiting and Development enterprises. in Southern Africa (2006) ISBN 1-920118-15-2Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< 45. Medical Recruiting:key stakeholders The Case inof theSouth South African African Health health Care sector, Professionals the paper (2007) ISBN offers1-920118-47-0 a series of recommendations for addressing the problem of 46. Voices From theskilled Margins: health Migrant migration. Women’s These Experiences recommendations in Southern are Africa grounded (2007) ISBN 1-920118-50-0in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- 47. The Haemorrhagement. of Health Professionals From South Africa: Medical Opinions (2007) ISBNThe paper978-1-920118-63-1 is organized into five sections. Section Two positions 48. The Qualitydebates ofabout Immigration the migration and Citizenship of skilled Services health in professionals Namibia (2008) within a ISBNwider 978-1-920118-67-9 literature that discusses the international mobility of talent. 49. Gender,Section Migration Three and reviews Remittances research in Southern on the globalAfrica circulation(2008) of health pro- ISBNfessionals, 978-1-920118-70-9 focusing in particular upon debates relating to the experience 50. The Perfectof countries Storm: inThe the Realities developing of Xenophobia world. Section in Contemporary Four moves South the Africafocus from (2008)international ISBN 978-1-920118-71-6 to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews 51. Migrant Remittances and Household Survival in Zimbabwe (2009) undertaken with health sector recruiters operating in South Africa. ISBN 978-1-920118-92-1 Section Five addresses the questions of changing policy interventions in 52. Migration,South Remittances Africa towards and ‘Development’ the outflow ofin skilledLesotho health (2010) professionals and the ISBNrecruitment 978-1-920409-26-5 of foreign health professionals to work in South Africa. The

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EXECUTIVE SUMMARY 53. Migration-Induced HIV and AIDS in Rural Mozambique and Swaziland (2011) ISBN 978-1-920409-49-4 ealth workers are one of the categories of skilled profession- 54. Medical Xenophobia: Zimbabwean Access to Health Services in South Africa als most affected by globalization. Over the past decade, (2011) ISBN 978-1-920409-63-0 there has emerged a substantial body of research that tracks 55. The Engagement of the Zimbabwean Medical Diaspora (2011) Hpatterns of international migration of health personnel, ISBN 978-1-920409-64-7 assesses causes and consequences, and debates policy responses at global 56. Right to the Classroom: Educational Barriers for Zimbabweans in South Africa and national scales. Within this literature, the case of South Africa is (2011) ISBN 978-1-920409-68-5 attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- 57. Patients Without Borders: Medical Tourism and Medical Migration in Southern oped countries. How to deal with the consequences of the resultant out- Africa (2012) ISBN 978-1-920409-74-6 flow of health professionals is a core policy issue for the national gov- 58. The Disengagement of the South African Medical Diaspora (2012) ernment. ISBN 978-1-920596-00-2 This paper aims to to examine policy debates and issues concerning 59. The Third Wave: Mixed Migration from Zimbabwe to South Africa (2012) the migration of skilled health professionals from the country and to ISBN 978-1-920596-01-9 furnish new insights on the recruitment patterns of skilled health personnel. The objectives of the paper are twofold: Q +CDFCJ=895B5I8=HC:H<9CF;5B=N5H=CB5B8D5HH9FBGC:F97FI=H ment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. Q 5G98IDCBH<956CJ95B5@MG=G5B8588=H=CB5@=BH9FJ=9KGK=H< key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruitment. The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from international to South African issues and provides new empirical material drawn from the survey of recruitment patterns and key interviews undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the recruitment of foreign health professionals to work in South Africa. The

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southern AfricAn MigrAtion ProgrAMMe Southern African Research Centre Kingston, Ontario, Canada