Migration-Induced Hiv and Aids in Rural Mozambique and Swaziland

tHe SoutHern african Migration PrograMMe

Migration-induced HiV and aidS in rural MozaMbique and Swaziland

Migration Policy SerieS no. 53

Migration-Induced HIV and AIDS in Rural Mozambique and Swaziland

Jonathan Crush, Ines Raimundo, Hamilton Simelane, Boaventura Cau and David Dorey

Series Editor: Prof. Jonathan Crush

Southern African Migration Programme (SAMP) International Organization for Migration (IOM) 2010 Acknowledgements We wish to thank the PHAMSA Program of the IOM (Pretoria) for funding the research on which this report is based. The survey was designed by a working group which included Mark Lurie, Krista House, David Dorey and Hamilton Simelane. Brian Williams alerted us to some important work in this area. We would like to thank all these colleagues for their input and assistance. Ashley Hill assisted with data analysis and report writing. Cassandra Eberhardt, Barbara Rijks, Maria Salamone, Katy Barwise and Searle Schonewille assisted with editing. We would also like to thank the IDRC for its support of SAMP and the DFID for funding the publication of this report.

Published by Idasa, 6 Spin Street, Church Square, Cape Town, 8001, and Southern African Research Centre, Queen's University, Canada.

ISBN 978-1-920409-49-4 First published 2010 Design by Bronwen Müller

All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without prior permission from the publishers. Bound and printed by Logo Print, Cape Town Contents Page

Executive Summary 1

Introduction 3

Mine Labour from Mozambique and Swaziland 5

HIV and AIDS in Rural Swaziland and Mozambique 9

Study Methodology 12

Profile of Respondents 15

Swaziland Survey Findings 17

Mozambique Survey Findings 21

Conclusion 27

Endnotes 30

Migration Policy Series 34

Tables Page

Table 1: Mine Migration to South Africa, 1920-2005 6

Table 2: age of Migrant Miners from Mozambique and Swaziland 8

Table 3: frequency of Return Home By Migrant Miners 8

Table 4: HIV Infection Trends Among ANC Respondents 11 by District, 1994-2002

Table 5: estimated Adult HIV Prevalence Rates, Mozambique, 2002 11

Table 6: average Monthly Income for Miners and Partners 16

Table 7: reasons for Not Using Condoms 25 Figures Page

Figure 1: Migrant Labour on South African Mines, 1990-2007 7

Figure 2: HIV Prevalence (ANC Respondents), 1992-2004 9

Figure 3: gaza Province and Chokwe District, Mozambique 13

Figure 4: Shiselweni District, Swaziland 14

Figure 5: Main Means of Protection Against HIV 18

Figure 6: Self-Assessment of Risk of Infection 18

Figure 7: number of Lifetime Sexual Partners 20

Figure 8: reason for Not Using Condom During Last Sexual Act 20

Figure 9: Perceived Methods of Contracting HIV/AIDS 22

Figure 10: Means of Protection from HIV 22

Figure 11: Main Causes of Death in Home Communities (Partners) 23

Figure 12: Women’s Reasons for Having Other Partners 26 MMIGRATIONigration PPOLICYolicy SERIESeries NOo. 4553

ExecutiXECUTIVEve SSuUMMARYmmary

outhealth Africa’s workers gold aremining one ofworkforce the categories has the of highest skilled prevalenceprofession- ratesals of most tuberculosis affected andby globalization. HIV infection Over of any the industrial past decade, sector in the therecountry. has The emerged contract a substantial migrant labour body ofsystem, research which that has tracks long outlivedpatterns apartheid, of international is responsible migration for this of unacceptable health personnel, situation. SHThe spread of HIV to rural communities in Southern Africa is not well assesses causes and consequences, and debates policy responses at global understood.and national The scales. accepted Within wisdom this literature, is that migrants the case leave of South for the Africa mines, is engageattracting in high-riskgrowing interest.behaviour, For contract almost 15the years virus Southand return Africa to has infect been theirthe target rural ofpartners. a ‘global This raiding’ model of fails skilled to deal professionals with the phenomenonby several devel- of rural-ruraloped countries. transmission How to anddeal cases with ofthe HIV consequences discordance of (when the resultant the female out- migrantflow of healthis infected professionals and the male is a core migrant policy not). issue Nor for does the itnational reveal whethgov- - erernment. all rural partners are equally at risk of infection. ThisThis studypaper examinesaims to to the examine vulnerability policy ofdebates rural partnersand issues in concerningsouth- ernthe Mozambiquemigration of skilledand southern health Swaziland,professionals which from are the two country major and source to areasfurnish for new migrant insights miners. on the It presents recruitment the resultspatterns of ofsurveys skilled with health miners per- andsonnel. partners The objectivesin these two of sending-areasthe paper are andtwofold: affords the opportunity to compare• To two provide different an auditmine-sending of the organization areas. The twoand areaspatterns are ofnot recruit- only geographicallyment of and skilled culturally professionals different, from they South have Africahad contrasting in the health experiences withsector. the Themine paper labour draws system upon over a detailedthe last twoanalysis decades. of recruitment The spread of HIV inadvertising Southern appearing Africa in thein the 1990s South coincided African with Medical major Journal downsizing for and retrenchmentthe period in2000-2004 the gold miningand a series industry of interviews which impacted conducted differ with- ently onprivate Mozambique recruiting and enterprises.Swaziland. Swaziland has been in decline as a source• of Based mine upon migrants the abovewhile Mozambiqueanalysis and additionalremained ainterviews relatively withstable source ofkey mine stakeholders migrants. inThe the study South therefore African aims health not sector,only to the shed paper light on vulnerabilityoffers a seriesin mine of recommendationssending areas, but foralso addressing to draw out the any problem contrasts of that mightskilled exist health between migration. two mine-sending These recommendations areas that were are inserted grounded into the minein migrant both South labour African system experience in different and ways an during interrogation the expansion of inter- of the HIVnational epidemic. debates and ‘good policy’ practice for regulating recruit- The ment.surveys collected data on (a) the age and socio-economic profiles of minersThe paper and partners;is organized (b) into migration five sections. behaviour Section (particularly Two positions how often migrantsdebates about returned the homemigration and offor skilled how long; health (c) professionalsthe knowledge within of and a atti- tudeswider towardsliterature HIV that and discusses AIDS amongthe international both groups; mobility (d) sexual of talent. behaviour andSection protection Three reviewsmeasures research against oninfection the global and circulation(e) perceptions of health of vulner pro-- abilityfessionals, and focusingrisk. Knowledge in particular of HIV upon and debates AIDS isrelating reasonably to the good experience amongst residentsof countries of both in the areas. developing Many of world. the common Section myths Four moves about theHIV focus are held from byinternational only a tiny tominority. South AfricanMost seem issues to knowand provides what puts new them empirical at risk, mate- know thatrial drawnthe disease from isthe fatal, survey know of recruitmentthat ART is patternsnot a remedy and key and interviews do not appearundertaken to have with a greathealth deal sector of faith recruiters in traditional operating healers. in South One Africa. exception isSection the rather Five large addresses proportion the questions of Mozambican of changing miners policy who interventions believe the dis in- easeSouth is Africacurable. towards If anything, the outflow rural partners of skilled are health better professionalsinformed than and min the- ers.recruitment In both Mozambiqueof foreign health and Swaziland,professionals the to main work source in South of knowledge Africa. The is not workplace programmes on the mines or in the community nor peer education nor the medical community, but radio. 1 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 Migration-Induced HIV and AIDS in Rural Mozambique and Swaziland

EXECUTIVE SUMMARY Perception of personal vulnerability is also high. Yet, both miners and female rural partners of migrants are at risk through their behaviour. ealth workers are one of the categories of skilled profession- The reasons, though, are quite different. In the case of miners, high risk als most affected by globalization. Over the past decade, behaviour is a consequence of the migrant labour system which sees them there has emerged a substantial body of research that tracks spend the greater part of the working year away from home in an all-male patterns of international migration of health personnel, environment of macho masculinity with easy access to transactional sex. H These miners are aware that condom use would reduce their risk of con- assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is tracting HIV but actual use is sporadic to non-existent. Condom use is attracting growing interest. For almost 15 years South Africa has been rejected on grounds of personal preference or attributed to forgetfulness. the target of a ‘global raiding’ of skilled professionals by several devel- Miners at home are even less likely to use condoms than when they oped countries. How to deal with the consequences of the resultant out- are on the mine. The risks of contracting HIV are certainly lower (since flow of health professionals is a core policy issue for the national gov- commercial sex workers on the mines exhibit much higher HIV preva- ernment. lence than rural partners). But their unwillingness to use protection puts This paper aims to to examine policy debates and issues concerning their rural partners at greatly increased risk. Rural partners perceive the migration of skilled health professionals from the country and to themselves to be at high risk precisely because their partners do not furnish new insights on the recruitment patterns of skilled health per- wish to use protection. Miners clearly expect their partners to be faithful sonnel. The objectives of the paper are twofold: and do not see themselves at risk when they go home. Any woman who • To provide an audit of the organization and patterns of recruit- insists on condom use is seen to be implicitly questioning her partner’s ment of skilled professionals from South Africa in the health fidelity. Women’s lack of use of condoms has virtually nothing to do with sector. The paper draws upon a detailed analysis of recruitment personal preference. Partners of migrant miners wish to use condoms to advertising appearing in the South African Medical Journal for protect themselves. Their inability to do so with the frequency and con- the period 2000-2004 and a series of interviews conducted with sistency that they would like is related to the demands of men for unpro- private recruiting enterprises. tected sex. Ultimately, therefore, it is the gendered relations of inequality • Based upon the above analysis and additional interviews with that make it very difficult for women to protect themselves against the key stakeholders in the South African health sector, the paper high-risk environment of the mines. offers a series of recommendations for addressing the problem of One of the basic hypotheses of this study was that different migration skilled health migration. These recommendations are grounded patterns affect the risk profile of miners and rural partners. Mozambican in both South African experience and an interrogation of inter- miners return home only once a year for annual leave. Swazi miners, in national debates and ‘good policy’ practice for regulating recruit- contrast, visit home at least once a month or every month or two. Yet, ment. both engage in equally risky behaviour while they are away at work. This The paper is organized into five sections. Section Two positions places Swazi women at greater personal risk than their Mozambican debates about the migration of skilled health professionals within a counterparts. wider literature that discusses the international mobility of talent. On the other hand, the comparison between Mozambican and Swazi Section Three reviews research on the global circulation of health pro- women suggests that the Mozambican partners may be more prone to fessionals, focusing in particular upon debates relating to the experience forming other relationships outside their primary relationship with their of countries in the developing world. Section Four moves the focus from usually absent partner for a host of different reasons including emotional international to South African issues and provides new empirical mate- and financial support. In some cases, increased poverty from a reduced rial drawn from the survey of recruitment patterns and key interviews flow of remittances may force some rural women to seek support through undertaken with health sector recruiters operating in South Africa. other relationships. 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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IEntroductionXECUTIVE SUMMARY

outhealth Africa’s workers gold aremining one ofworkforce the categories has the of highest skilled prevalenceprofession- ratesals of most HIV affected and TB byinfection globalization. of any industrialOver the sectorpast decade, in the 1 country.there Inhas the emerged late 1980s, a substantial HIV prevalence body of researchamongst thatmigrant tracks 2 minerspatterns was less of international than 1%. Only migration ten years of later,health it personnel,was over 25% SHand still climbing.3 HIV infection, in turn, dramatically increases vulner- assesses causes and consequences, and debates policy responses at global abilityand national to TB. scales.TB prevalence Within thisincreased literature, from the 806 case per of100,000 South inAfrica 1991 is 4 toattracting 3,821 per growing 100,000 interest. in 2004 For to almostover 7,000 15 years per 100,000 South Africa in 2009. has Thebeen contractthe target migrant of a ‘global labour raiding’ system, of which skilled has professionals long outlived by apartheid,several devel- is 5 responsibleoped countries. for this How situation. to deal withAbsence the consequences from home, a ofculture the resultant of macho out- maleflow ofsexuality health onprofessionals the mines, is the a coreready policy availability issue for of thecasual national and com gov-- mercialernment. sex, and the constant fear and personal experience of death and dismembermentThis paper aims underground, to to examine all place policy miners debates at veryand issueshigh risk concerning of HIV 6 infection.the migration of skilled health professionals from the country and to furnishThe newintimate insights connection on the recruitmentbetween migration patterns and of skilledinfectious health disease per- pre-datessonnel. The the objectives advent of ofHIV the and paper AIDS. are twofold:Indeed, it as old as the migrant labour• system To provide itself. anSince audit the of beginning the organization of South and Africa’s patterns gold of mining recruit- industryment in the of late skilled nineteenth professionals century, from labour South migration Africa in has the impacted health on the healthsector. of The migrant paper miners draws uponand their a detailed rural partners analysis inof Southrecruitment Africa 7 and neighbouringadvertising countries. appearing Particularlyin the South devastating African Medical were the Journal lung and for infectiousthe diseases period (such2000-2004 as STIs and and a seriesTB), thatof interviews accompanied conducted poor work with- ing conditionsprivate and recruiting long periods enterprises. of separation and relationship disruption. In the• words Based of upon Shula the Marks, above pre-existing analysis and patterns additional of oscillating interviews labour with migrationkey in stakeholders Southern Africa in the rendered South AfricanHIV and health AIDS sector, an “epidemic the paper 8 waiting offersto happen.” a series of recommendations for addressing the problem of Althoughskilled there health is now migration. a large Theseliterature recommendations on the vulnerability are grounded of male migrant inworkers both South to HIV, African the relationship experience between and an migrationinterrogation and ofthe inter- 9 spread ofnational HIV to debatesrural communities and ‘good policy’ is imperfectly practice understood. for regulatingThe recruit- con- ventionalment. wisdom is captured in a somewhat one-dimensional model: migrantsThe paper leave isfor organized the mines, into engage five sections. in high-risk Section behaviour, Two positions contract the virusdebates and about return the to migration infect their of unprotectedskilled health rural professionals partners. Inwithin the case a ofwider Mozambique, literature thatfor example, discusses Collins the international argues that mobilitythe higher of ratetalent. of HIV prevalenceSection Three in the reviews centre research and south on (comparedthe global circulationto other parts of healthof the counpro- - try)fessionals, is directly focusing related in toparticular the influence upon ofdebates migrant relating labour to to the the experience South Africanof countries mines: in “Risingthe developing prevalence world. levels Section in this Four region moves in part the reflect focus from increasedinternational commercial to South and African migrant issues mineworker and provides travel new south empirical since the mate- 1992rial drawn peace from agreement. the survey An ofestimated recruitment 50,000 patterns Mozambicans, and key interviewsmost from theundertaken southern with and healthcentral sector regions, recruiters currently operating work in inSouth South African Africa. mines, whereSection HIV Five rates addresses are very the high. questions Many ofof changingthem return policy home interventions on annual in 10 leaveSouth infected Africa towardswith HIV the and outflow infect of their skilled wives.” health According professionals to this and the model,recruitment the virus of foreign spreads health to rural professionals areas purely to by work infected in South male Africa. migrants The returning home and infecting their partners. Darrell Roodt’s 2004 award-

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EXECUTIVE SUMMARY winning movie Yesterday is a classic representation of this model, accompanied (for dramatic effect) by the stigmatization and expulsion of the ealth workers are one of the categories of skilled profession- migrant and his female partner from the rural community.11 als most affected by globalization. Over the past decade, Recent research undertaken in migrant-sending areas in the KwaZulu there has emerged a substantial body of research that tracks Natal province of South Africa challenges this model of transmission patterns of international migration of health personnel, from migrants to rural partners.12 The study compared “migrant couples” H (in which at least one of the partners migrated for work) to “non-migrant assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is couples” and found that the former were more likely to have one or both attracting growing interest. For almost 15 years South Africa has been partners infected with HIV (35% versus 19%). These couples were also the target of a ‘global raiding’ of skilled professionals by several devel- more likely to be HIV discordant (27% versus 15%) i.e. one partner oped countries. How to deal with the consequences of the resultant out- is infected and the other not. However, the research also showed that flow of health professionals is a core policy issue for the national gov- amongst couples in which only one partner was infected, in nearly a third ernment. of cases (30%) the migrant was actually HIV-negative and the rural part- This paper aims to to examine policy debates and issues concerning ner was HIV positive. Clearly, an HIV-positive woman whose migrant the migration of skilled health professionals from the country and to spouse is not infected must have been infected by someone else. This furnish new insights on the recruitment patterns of skilled health per- suggests that a more nuanced understanding is needed of the risk behav- sonnel. The objectives of the paper are twofold: iours of both migrants and their rural partners and the responses required • To provide an audit of the organization and patterns of recruit- to reduce personal vulnerability to infection. ment of skilled professionals from South Africa in the health In practice, there are many mediating factors affecting the vulner- sector. The paper draws upon a detailed analysis of recruitment ability of female partners to infection by a male migrant.These include advertising appearing in the South African Medical Journal for the recency and acuteness of male infection, his viral load, the presence the period 2000-2004 and a series of interviews conducted with of genital ulceration, herpes simplex virus-2 positivity, concurrency, male private recruiting enterprises. circumcision and age.13 Coffee et al have modeled the impact of migra- • Based upon the above analysis and additional interviews with tion on the HIV epidemic using data from Kwazulu-Natal and find that key stakeholders in the South African health sector, the paper migration primarily influences the spread of HIV by increasing high-risk offers a series of recommendations for addressing the problem of behaviour, rather than by connecting areas of low and high risk.14 The skilled health migration. These recommendations are grounded model also predicts that if migration is accompanied by increased sexual in both South African experience and an interrogation of inter- risk behaviour by migrant men, HIV prevalence among female partners national debates and ‘good policy’ practice for regulating recruit- increases tenfold. In contrast, if migration occurs infrequently, the pre- ment. dicted epidemic would be only one fifth of that currently observed. For The paper is organized into five sections. Section Two positions a given level of high risk behaviour by migrants, the frequency of return debates about the migration of skilled health professionals within a home would also dramatically affect the risk of contracting HIV by rural wider literature that discusses the international mobility of talent. partners. Another critical factor impacting on the vulnerability of rural Section Three reviews research on the global circulation of health pro- partners is the nature of gender relations between men and women in fessionals, focusing in particular upon debates relating to the experience the rural migrant sending areas. Amongst other things, this influences of countries in the developing world. Section Four moves the focus from the degree to which, and with what consequences, rural women can take international to South African issues and provides new empirical mate- measures to protect themselves against infection. rial drawn from the survey of recruitment patterns and key interviews The spread of HIV in Southern Africa in the 1990s coincided with undertaken with health sector recruiters operating in South Africa. major downsizing and retrenchment in the mining industry. The South Section Five addresses the questions of changing policy interventions in African gold mines lost over 150,000 jobs after 1990 (with employment South Africa towards the outflow of skilled health professionals and the levels dropping from 406,000 in 1990 to 230,000 in 2004). To the extent recruitment of foreign health professionals to work in South Africa. The that migrants were precluded from working any longer on the mines, they and their partners became less vulnerable to infection since they were no

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EXECUTIVElongerS UMMARYexposed to high-risk situations on the mines. These massive job losses profoundly impacted on migrant-sending communities and exacer- bated alreadyealth high workers levels ofare unemployment. one of the categories15 of skilled profession- The newals economic most affected reality by forced globalization. a number Over of women the past to enterdecade, the workforce andthere engage has emerged in forms aof substantial cross-border body trade of researchto supplement that tracks household income.patterns As of ainternational result, the female migration members of health of the personnel, households of Hformer mine migrants themselves potentially became more vulnerable to assesses causes and consequences, and debates policy responses at global HIVand nationalas the conditions scales. Within in which this they literature, lived and the workedcase of inSouth cities Africa and on is farmsattracting increased growing their interest. vulnerability. For almost 15 years South Africa has been theIn target order of to a examine‘global raiding’ the vulnerability of skilled professionalsto HIV infection by several of rural devel- part- ners,oped twocountries. contrasting How mineto deal migrant with the sending consequences areas were of chosenthe resultant for this out- study:flow of southern health professionals Mozambique is and a core southern policy Swaziland.issue for the The national two areas gov- are noternment. only geographically and culturally different, they have had contrasting Thisexperiences paper aims with to the to mineexamine labour policy system debates over andthe lastissues two concerning decades. Onethe migration (Swaziland) of skilledhas been health in decline professionals as a source from of the mine country migrants; and theto otherfurnish (Mozambique) new insights onhas the been recruitment a relatively patterns stable source of skilled of mine health migrants. per- Thesonnel. study The therefore objectives aims of not the only paper to are shed twofold: light on the parameters of vulnerability• To provide in mine an sending audit of areas, the organization but also to draw and patternsout any contrastsof recruit- that mightment exist of skilledbetween professionals two mine-sending from South areas Africathat have in the been health inserted into thesector. mine migrant The paper labour draws system upon in a differentdetailed analysisways at theof recruitment height of the HIV epidemic.advertising appearing in the South African Medical Journal for the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. Mine Labour• Basedfrom upon Moza the abovembique analysis and and Swaziland additional interviews with key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of Downsizing theskilled Workforce health migration. These recommendations are grounded in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- or many decades, southern Mozambique and southern Swaziland ment. have been major source areas for male migrant workers on the The paper is organized into five sections. Section Two positions South African gold mines.16 The numbers from Mozambique rose debates about the migration of skilled health professionals within a steadily in the decades after 1920, peaking at just over 100,000 in wider literature that discusses the international mobility of talent. F1960 (Table 1). The numbers from Swaziland were always lower (though Section Three reviews research on the global circulation of health pro- comparable in terms of the proportion of the population) and peaked fessionals, focusing in particular upon debates relating to the experience much later (in 1990). The sudden drop in Mozambique between 1975 of countries in the developing world. Section Four moves the focus from and 1980 came right after independence. Fearing that the new socialist international to South African issues and provides new empirical mate- government would withdraw all Mozambican miners, the mining compa- rial drawn from the survey of recruitment patterns and key interviews nies quickly sought out new sources of labour. Swaziland was one of the undertaken with health sector recruiters operating in South Africa. beneficiaries as the number of Swazi miners doubled between 1975 and Section Five addresses the questions of changing policy interventions in 1990. 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 Table 1: Mine Migration to South Africa, 1920-2005 Year Mozambique Swaziland ealth workers are one of the categories of skilled profession- 1920 77,921 3,449 als most affected by globalization. Over the past decade, 1925 73,210 3,999 there has emerged a substantial body of research that tracks 1930 77,828 4,345 patterns of international migration of health personnel, H 1935 62,576 6,865 assesses causes and consequences, and debates policy responses at global 1940 74,693 7,152 and national scales. Within this literature, the case of South Africa is 1945 78,588 5,688 attracting growing interest. For almost 15 years South Africa has been 1950 86,246 6,619 the target of a ‘global raiding’ of skilled professionals by several devel- 1955 99,449 6,682 oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- 1960 101,733 6,623 ernment. 1965 89,191 5,580 This paper aims to to examine policy debates and issues concerning 1970 93,203 6,269 the migration of skilled health professionals from the country and to 1975 97,216 8,391 furnish new insights on the recruitment patterns of skilled health per- 1980 39,539 8,090 sonnel. The objectives of the paper are twofold: 1985 50,126 12,365 • To provide an audit of the organization and patterns of recruit- 1990 43,951 16,618 ment of skilled professionals from South Africa in the health 1995 53,321 14,611 sector. The paper draws upon a detailed analysis of recruitment 2000 44,245 8,079 advertising appearing in the South African Medical Journal for 2005 46,256 6,878 the period 2000-2004 and a series of interviews conducted with Source: Crush, Jeeves and Yudelman, South Africa’s Labor Empire; TEBA. private recruiting enterprises. • Based upon the above analysis and additional interviews with When HIV arrived on the mines in the late 1980s, the number of key stakeholders in the South African health sector, the paper Swazi miners was over 40% of the number of Mozambicans. However, offers a series of recommendations for addressing the problem of this scenario changed very quickly in the 1990s. Swaziland experienced skilled health migration. These recommendations are grounded major downsizing of its mine workforce while Mozambique did not. As in both South African experience and an interrogation of inter- Figure 1 shows, although the number of Mozambican miners fluctuated national debates and ‘good policy’ practice for regulating recruit- during the 1990s, there were more in 2003 than there had been in 1990. ment. Over the same time period, the mine workforce from Swaziland was The paper is organized into five sections. Section Two positions cut in half. By 2007, the number of Swazi miners was only 20% of the debates about the migration of skilled health professionals within a number of Mozambican miners. wider literature that discusses the international mobility of talent. The reasons for this change in recruiting patterns in the 1990s have Section Three reviews research on the global circulation of health pro- never been properly explained. The rate of Swazi retrenchments was fessionals, focusing in particular upon debates relating to the experience comparable to that in Lesotho, Botswana and South Africa itself. So the of countries in the developing world. Section Four moves the focus from question is really why Mozambique did not experience a similar decline international to South African issues and provides new empirical mate- and why the proportion of Mozambicans in the workforce increased from rial drawn from the survey of recruitment patterns and key interviews 10% to 25% over the course of the decade. One possible explanation is undertaken with health sector recruiters operating in South Africa. that Mozambicans were not well-represented on the mines that suffered Section Five addresses the questions of changing policy interventions in most lay-offs. Another is that Mozambican miners were less militant than South Africa towards the outflow of skilled health professionals and the their South African counterparts and were therefore preferred by employ- recruitment of foreign health professionals to work in South Africa. The ers. However, general levels of militancy on the mines declined amongst all mineworkers after 1990. It is likely that the HIV and AIDS epidemic

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EXECUTIVEalso playedSUMMARY a role. Mine managers would have quickly realised that HIV prevalence was lower in Mozambique than in other sources areas like Swazilandealth and workers Lesotho. are As one miners of the were categories retrenched, of skilled it would profession- have made sense alsto minemost managersaffected by to globalization. recruit any new Over workers the past from decade, a region with much lowerthere generalhas emerged rates aof substantial infection. Andbody that of research really only that meant tracks fig HMozambique.1.pdf 1 26/11/2010patterns of11:59 international AM migration of health personnel, assesses causes and consequences, and debates policy responses at global Figure 1: Migrant Labour on South African Mines, 1990-2007 and national scales. Within this literature, the case of South Africa is 60 000 – attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- 50 000 – oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- 40 000 – ernment. This paper aims to to examine policy debates and issues concerning

30 000 – the migration of skilled health professionals from the country and to furnish new insights on the recruitment patterns ofMozambique skilled health personnel. The objectives of the paper are twofold: Swaziland 20 000 – • To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health 10 000 – sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for 0 – the period 2000-2004 and a series of interviews conducted with 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 private recruiting enterprises. • Based upon the above analysis and additional interviews with key stakeholders in the South African health sector, the paper HIV/AIDS and the Changing Age Profile of Migrant Miners offers a series of recommendations for addressing the problem of Decliningskilled employment health migration. opportunities These for recommendationsmigrants in the post-1990 are grounded mining industryin both meant South that African the average experience age of andthose an who interrogation remained beganof inter- to rise. A 1997national SAMP debates survey and of ‘goodMozambican policy’ practiceminers found for regulating that only recruit- 5% were underment. the age of 35 while 61% were over the age of 45.17 Another SAMPThe survey paper onlyis organized eight years into later five showedsections. a Sectiondramatic Two change positions in the age compositiondebates about of the the migrationMozambican of skilled mine workforce.health professionals Now 39% withinwere under a thewider age literature of 35 and that only discusses 29% were the over international the age of mobility45. The mostof talent. plausible explanationSection Three for reviewsthis dramatic research shift on in the age global profile circulation is HIV and of AIDS. health professionals,Older miners focusing were in gettingparticular too upon sick todebates work orrelating dying toof theAIDS experience and theyof countries were being in the replaced developing by younger, world. HIV Section negative, Four movesmen from the ruralfocus from Mozambique.international Ato keySouth question African (which issues this and paper provides sets newout toempirical answer) mate- is whetherrial drawn these from miners, the survey who ofjoined recruitment the industry patterns in a andperiod key of interviews heightened awarenessundertaken about with HIVhealth and sector AIDS, recruiters are less operatingsusceptible in to South infection Africa. than theSection previous Five generation.addresses the After questions 2002, theof changing number ofpolicy miners interventions recruited from in MozambiqueSouth Africa begantowards to thedecline outflow (from of 52,000skilled inhealth 2003 professionals to 45,000 in and2007). the Therecruitment reason could of foreign be the health undoubted professionals political to pressure work in to South hire SouthAfrica. The Africans (something the mines had successfully resisted for decades) or it

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EXECUTIVE SUMMARY could be that with rates of HIV on the rise in rural Mozambique, a long- standing competitive advantage of Mozambique came to an end. ealth workers are one of the categories of skilled professionals most affected by globalization. Over the past decade, Table 2: Age of Migrant Miners from Mozambique and Swaziland there has emerged a substantial body of research that tracks Age of Miners Mozambique (1997) (%) Mozambique (2005) (%) Swaziland (2005) (%) Hpatterns of international migration of health personnel, <35 5 39 19 assesses causes and consequences, and debates policy responses at global 35-39 10 18 28 and national scales. Within this literature, the case of South Africa is 40-44 24 14 25 attracting growing interest. For almost 15 years South Africa has been 45-49 39 9 16 the target of a ‘global raiding’ of skilled professionals by several devel- 50-54 14 11 7 oped countries. How to deal with the consequences of the resultant out- 55-59 6 7 4 flow of health professionals is a core policy issue for the national gov- >60 2 2 1 ernment. Source: SAMP Surveys This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to Age data for miners from Swaziland is only available for 2005. What furnish new insights on the recruitment patterns of skilled health per- this suggests is that there has been little ‘new blood’ from Swaziland for sonnel. The objectives of the paper are twofold: some time (with only 19% under 35 compared with Mozambique’s 39%). • To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment Mobility and Vulnerability advertising appearing in the South African Medical Journal for The 2005 SAMP Survey revealed dramatic differences in the frequency the period 2000-2004 and a series of interviews conducted with of home visits by miners from Mozambique and Swaziland. In the case private recruiting enterprises. of Mozambique, two thirds of miners returned only once or twice a year • Based upon the above analysis and additional interviews with and another 21% less than once a year. In contrast, nearly half of the key stakeholders in the South African health sector, the paper Swazi migrants returned home at least once a month and another 37% at offers a series of recommendations for addressing the problem of least once every three months. Only 13% returned once or twice a year. skilled health migration. These recommendations are grounded Around 87% of miners in both countries are married or cohabiting. in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- Table 3: Frequency of Return Home By Migrant Miners ment. Mozambique (%) Swaziland (%) The paper is organized into five sections. Section Two positions > Twice a Month 2 7 debates about the migration of skilled health professionals within a Once a Month 2 41 wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health pro- > Twice in Three Months 1 19 fessionals, focusing in particular upon debates relating to the experience Once Every Three Months 9 18 of countries in the developing world. Section Four moves the focus from Once Every Six Months 29 7 international to South African issues and provides new empirical mate- Once a Year 37 6 rial drawn from the survey of recruitment patterns and key interviews Less Than Once A Year 21 2 undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in Epidemiologists have shown that the probability of HIV infection South Africa towards the outflow of skilled health professionals and the within an HIV discordant couple is related to the frequency of sexual recruitment of foreign health professionals to work in South Africa. The intercourse. In general,the risk of HIV infection for rural women increases with the frequency of sexual relations with their migrant partners. In

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EXECUTIVEthe contextSUMMARY of a migrant labour system, frequency is partly a function of how often partners are able to see one another. The frequency with which minersealth return workers home are is thereforeone of the a categoriesgeneral surrogate of skilled measure profession- of the degree ofals risk most of affectedinfection by for globalization. their partners. Over Holding the past all otherdecade, factors equal, the riskthere of HIVhas emerged infection a fromsubstantial unprotected body of sex research is clearly that much tracks Hhigher amongstpatterns rural of partners international in Swaziland migration than of in health Mozambique. personnel, assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is HIV andattracting AIDS growingin Rural interest. Swaziland For almost and15 years M ozaSouthm Africabique has been the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- Swazilandflow: F ofull health-Blown professionals AIDS is a core policy issue for the national government. This paper aims to to examine policy debates and issues concerning he first reported case of AIDS in Swaziland was in 1987. Today, the migration of skilled health professionals from the country and to it has one of the highest rates of HIV infection in the world. In furnish new insights on the recruitment patterns of skilled health per- 1992, the first ante-natal clinic (ANC) survey was carried out sonnel. The objectives of the paper are twofold: and showed an HIV prevalence of 3.9%. In 1994, prevalence • To provide an audit of the organization and patterns of recruit- Thad jumped to 16.1% and in 2002 to 38.5%.18 By 2004, the rate had ment of skilled professionals from South Africa in the health jumped again to 42.6% (Figure 2).19 Rates of HIV infection are high- sector. The paper draws upon a detailed analysis of recruitment est among women of child-bearing age in their 20s and 30s. The impact advertising appearing in the South African Medical Journal for of the epidemic is being felt throughout the country. The death rate the period 2000-2004 and a series of interviews conducted with increased from 11 to 20 per 1000 population between 1997 and 2003 private recruiting enterprises. and the infant mortality rate increased from 88 to 109 per 1000 over the • Based upon the above analysis and additional interviews with same time period. Life expectancy has fallen to 40 for males and 41 for key stakeholders in the South African health sector, the paper figfemales. 2.pdf 120 26/11/2010 12:04 PM offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded Figure 2: HIV Prevalence (ANC Respondents), 1992-2004 in both South African experience and an interrogation of inter- 50 – national debates and ‘good policy’ practice for regulating recruitment. 40 – 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. 30 – Section Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience

Percentage 20 – 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 10 – undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in

0 – South Africa towards the outflow of skilled health professionals and the 1992recruitment1994 of foreign1996 health professionals1998 to2000 work in South2002 Africa.2004 The

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EXECUTIVE SUMMARY The dramatic spread of HIV in Swaziland has been attributed to high levels of internal mobility and cross-border migration to South ealth workers are one of the categories of skilled profession- Africa. Whiteside, for example, argues that the people of Swaziland are als most affected by globalization. Over the past decade, “extremely mobile” within the country and, in addition, “there is con- there has emerged a substantial body of research that tracks siderable cross border mobility, particularly to South Africa.”21 He draws patterns of international migration of health personnel, particular attention to migrant miners who “travel as single men for peri- H ods of up to a year.”22 In fact, though their employment contracts are a assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is year long, Swazi migrants return home quite frequently during the year. attracting growing interest. For almost 15 years South Africa has been This only magnifies the vulnerability of their rural partners. the target of a ‘global raiding’ of skilled professionals by several devel- After the end of apartheid, cross-border movement between oped countries. How to deal with the consequences of the resultant out- Swaziland and South Africa increased dramatically. Legal border cross- flow of health professionals is a core policy issue for the national gov- ings from Swaziland to South Africa grew from under 200,000 in 1991 to ernment. over 800,000 in 2003.23 While mobility is widely said to increase vulner- This paper aims to to examine policy debates and issues concerning ability to HIV, different forms and frequencies of movement impact dif- the migration of skilled health professionals from the country and to ferently on vulnerability.24 With regard to Swazi miners, Whiteside argues furnish new insights on the recruitment patterns of skilled health per- that the vulnerability of Swazi miners is attributable to anonymity, loneli- sonnel. The objectives of the paper are twofold: ness, an inability to maintain stable relationships and an environment • To provide an audit of the organization and patterns of recruit- where life is cheap.25 These increase the likelihood of non-regular sex ment of skilled professionals from South Africa in the health and sexually transmitted infections. The mine environment also gener- sector. The paper draws upon a detailed analysis of recruitment ates a machismo culture conducive to sexual behaviours that put miners advertising appearing in the South African Medical Journal for at considerable risk.26 the period 2000-2004 and a series of interviews conducted with ANC HIV prevalence rates in the southern Shiselweni District private recruiting enterprises. (where this research took place) are comparable to those in the other • Based upon the above analysis and additional interviews with three districts of the country (Table 4). As Whiteside points out, the key stakeholders in the South African health sector, the paper epidemic is “uniformly bad” in Swaziland with little difference between offers a series of recommendations for addressing the problem of rural and urban areas and between districts.27 Others have argued that skilled health migration. These recommendations are grounded although Shiselweni does not have the highest HIV prevalence, it does in both South African experience and an interrogation of inter- have the highest number of AIDS-related deaths.28 This they attribute national debates and ‘good policy’ practice for regulating recruit- to the greater incidence of poverty and migration patterns out of ment. Shiselweni. The 1997 Swaziland Census showed that Shiselweni District The paper is organized into five sections. Section Two positions had the highest rate of out-migration with 90% of migrants moving inter- debates about the migration of skilled health professionals within a nally to Manzini.29 In other words, many Shiselweni residents with HIV wider literature that discusses the international mobility of talent. are living and working in Manzini, pushing up that region’s prevalence Section Three reviews research on the global circulation of health pro- rate. At the same time, people with full-blown AIDS who can no longer fessionals, focusing in particular upon debates relating to the experience work invariably return to their home Shiselweni region to die. As mine of countries in the developing world. Section Four moves the focus from migrants with HIV become ill and are unable to work on the mines, they international to South African issues and provides new empirical mate- too return to Shiselweni. rial 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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ETableXECUTIVE 4: HIV InfectionSUMMARY Trends Among ANC Respondents by District, 1994-2002 Region 1994 1996 1998 2000 2002 Hhohho 15.5ealth workers26.3 are one of 30.3the categories32.3 of skilled profession-36.6 Lubombo 16.8als most affected26.5 by globalization.31.5 Over34.5 the past decade,38.5 Manzini 15.6there has emerged27.7 a substantial34.8 body of 41research that41.2 tracks patterns of international migration of health personnel, ShiselweniH16.8 23.9 29.6 27 37.9 Source: Whiteside,assesses 2003, causes p. 15. 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 Mozambiquethe target: HIV of R ais ‘globaling raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- Afterflow of a slowerhealth start,professionals HIV is nowis a corespreading policy rapidly issue for in ruralthe national Mozambique. gov- Inernment. 2004, the national infection rate was estimated at 16.2%. An esti- matedThis 500 paper new aims infections to to examine occur each policy day. debates30 As in andthe issuesrest of concerning the region, thethe HIVmigration epidemic of skilled in Mozambique health professionals has particularly from theaffected country women. and toThe prevalencefurnish new rate insights for young on the women recruitment between patterns the ages of of skilled 15 and health 19 is per-twice thatsonnel. of young The objectives men. Women of the between paper are20 andtwofold: 24 are four times more likely to have• ToHIV provide than their an audit male of peers. the organization31 As Table 5 and shows, patterns rates ofin recruit-the North arement much of skilledlower than professionals in the Centre from Southand South. Africa32 in the health sector. The paper draws upon a detailed analysis of recruitment Table 5: Estimated Adultadvertising HIV Prevalence appearing Rates, in Mozambique,the South African 2002 Medical Journal for Region the periodProvince 2000-2004 and a series of interviewsPrevalence Rates conducted with private recruiting enterprises.Provincial % Regional % South • BasedMaputoCity upon the above analysis and13 additional interviews13.2 with key stakeholdersMaputo Province in the South African14.3 health sector, the paper offersGaza a series of recommendations16 for addressing the problem of skilled health migration. These recommendations are grounded Inhambane 9.6 in both South African experience and an interrogation of inter- Centre Sofala 18.7 16.5 national debates and ‘good policy’ practice for regulating recruit- Manica 21.1 ment. Tete 19.8 The paper is organized into five sections. Section Two positions debates aboutZambezia the migration of skilled health12.7 professionals within a North wider literatureNampula that discusses the international5.2 mobility of talent.5.7 Section ThreeNiassa reviews research on the global6.8 circulation of health professionals, focusingCabo Delgado in particular upon debates6.4 relating to the experience Mozambiqueof Nationalcountries in the developing world. Section Four moves the12.2 focus from Sources: Ministryinternational of Health (2002)to South and MinistryAfrican of Healthissues etand al. (2001),provides based new on observationsempirical mate- from 20 health posts,rial drawn some of from them ruralthe survey(Arndt 2003: of recruitment 2) patterns and key interviews undertaken with health sector recruiters operating in South Africa. SectionRegional Five differences addresses thein HIV questions prevalence of changing have been policy related interventions to internal in 33 andSouth external Africa population towards the movements. outflow of skilledBeckmann health and professionals Rai, for example, and the arguerecruitment that a numberof foreign of healthoverlapping professionals mobility-related to work infactors South are Africa. responsi The- ble for the rapid spread of HIV in Mozambique:

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EXECUTIVE SUMMARY The epidemic has been fuelled by the return of refugees from neighbouring countries, the introduction of peacekeep- ealth workers are one of the categories of skilled profession- ing forces from high-prevalence countries, and a marked als most affected by globalization. Over the past decade, increase in cross-border trade. The impact of the move- there has emerged a substantial body of research that tracks ment of troops from West Africa is thought to be part of the patterns of international migration of health personnel, cause of the spread of HIV-2 in Mozambique, as military H personnel have higher prevalence rates and tend to exhibit assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is risky behaviour. The railway line that passes by Gaza links attracting growing interest. For almost 15 years South Africa has been Mozambique with South Africa and Zimbabwe. During the the target of a ‘global raiding’ of skilled professionals by several devel- war in the 1980s, the trains transporting relief food were oped countries. How to deal with the consequences of the resultant out- guarded by soldiers from the latter countries. As a result of flow of health professionals is a core policy issue for the national gov- the dire conditions, prostitution increased in that region. ernment. In southern Mozambique, miners with relatively high wages This paper aims to to examine policy debates and issues concerning meet the staggering poverty of rural women struggling to the migration of skilled health professionals from the country and to make a living. This combination of poverty and inequality furnish new insights on the recruitment patterns of skilled health per- greatly favours the spread of HIV.34 sonnel. The objectives of the paper are twofold: A 2002 UNESCO study suggested that a number of socio-cultural • To provide an audit of the organization and patterns of recruit- factors were also facilitating the spread of HIV: initiation rites, polyga- ment of skilled professionals from South Africa in the health mous marriages, religious practices, death rites, taboos, witchcraft and sector. The paper draws upon a detailed analysis of recruitment commercial sex.35 advertising appearing in the South African Medical Journal for Access to health care in rural Mozambique is particularly poor. Less the period 2000-2004 and a series of interviews conducted with than 40% of the population has access to basic services. Poor transporta- private recruiting enterprises. tion and communications infrastructure mean that many areas of the • Based upon the above analysis and additional interviews with country cannot access services when needed. Beckman and Rai found key stakeholders in the South African health sector, the paper that the services that are provided in Mozambique are often inadequate offers a series of recommendations for addressing the problem of and provide questionable information and educational services.36 They skilled health migration. These recommendations are grounded conclude, “the level of knowledge of AIDS is very low in all ranks of in both South African experience and an interrogation of inter- health-care workers. Most health workers are unable to provide complete national debates and ‘good policy’ practice for regulating recruit- information to patients and are not trained to treat opportunistic infec- ment. tions.”37 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. Study Methodology Section Three reviews research on the global circulation of health pro- he primary objective of the research was to examine the vul- fessionals, focusing in particular upon debates relating to the experience nerability to HIV and AIDS of the rural partners of migrant of countries in the developing world. Section Four moves the focus from miners. This population has been largely ignored in the exist- international to South African issues and provides new empirical mate- ing literature on the mining sector which tends to focus on rial drawn from the survey of recruitment patterns and key interviews Tmineworkers themselves and their vulnerability at the place of work. The undertaken with health sector recruiters operating in South Africa. research was planned by a SAMP working group which first developed Section Five addresses the questions of changing policy interventions in and tested a common questionnaire for use in both sites. As the project South Africa towards the outflow of skilled health professionals and the developed, it became clear that the vulnerability of rural women was recruitment of foreign health professionals to work in South Africa. The intimately connected both to their own material and social circumstances and to the behaviours and attitudes of their migrant partners.

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EXECUTIVEHence,SUMMARY a twin focus developed on migrant miners (who were all interviewed while at home) and their rural partners. Not only did this approach provideealth workersinsights areinto one the of vulnerability the categories of theof skilled rural partners, profession- it also providedals an most opportunity affected byto globalization.make comparisons Over between the past thedecade, behaviour and attitudesthere has of theemerged two groups. a substantial In other body words, of research the research that trackspermit- ted two axespatterns of comparison: of international first, between migration two differentof health mine-sending personnel, Hareas, and second, between migrant men and their rural partners. assesses causes and consequences, and debates policy responses at global andThe national vast majority scales. Within of Mozambican this literature, mine migrantsthe case comeof South from Africa the south is ofattracting the country. growing38 Approximately interest. For almost40% of 15miners years are South from Africa Gaza hasProvince, been 28%the target from Inhambaneof a ‘global andraiding’ 27% of from skilled Maputo. professionals A SAMP by studyseveral in devel-the lateoped 1990s countries. showed How that to within deal with Gaza the Province, consequences 27% of of miners the resultant were from out- Xaiflow Xai of healthDistrict, professionals 21% from Chokwe is a core District, policy issue 20% for from the Chibuto, national 15% gov- fromernment. Manjacaze and 9% from Bilene/Macia.39 The area in Mozambique chosenThis for paper the aimsstudy to was to theexamine Chokwe policy District debates of Gaza and issuesProvince concerning (Figure 3).the The migration district of was skilled selected health because professionals of its well-established from the country historical and to ties tofurnish mine newmigration insights to onSouth the Africarecruitment and its patterns contemporary of skilled importance health per- as asonnel. mine-sending The objectives area.40 Atof thethe papertime of are the twofold: survey, Chokwe District supplied• approximately To provide an 4,000 audit miners of the to organization the South African and patterns mines, of second recruit- in importancement only of skilledto Xai professionalsXai. The HIV from prevalence South Africarate for in the the Chokwe health District sector.was estimated The paper by thedraws Ministry upon aof detailed Health analysisto be 22% of ofrecruitment all adults in 2003.advertising41 The interviews appearing were in conducted the South in African three communities Medical Journal within for the District: Chilembene, Macarretane and the regional capital of fig 4 map.pdfthe period 1 02/02/20112000-2004 10:56 and AMa series of interviews conducted with Chokweprivate itself. recruiting enterprises. • Based upon the above analysis and additional interviews with Figure 3: Gaza Provincekey andstakeholders Chokwe District, in the Mozambique South African health sector, the paper offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded Southernin both Mozambique 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 professionalsMacceretane within a wider literature that discusses the international mobility of talent. Section Three reviews research on the globalChokwe circulation of health professionals, focusing in particular upon debates relating Chilembeneto 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 Gaza Province undertaken with healthChokwe sector District 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 In the case of Swaziland, the Shiselweni District in the south of the country has always supplied a disproportionate number of migrant min- 42 ealth workers are one of the categories of skilled profession- fig 5 map.pdf 1 24/01/2011ers. The2:05 researchPM was conducted in several different rural parts of the als most affected by globalization. Over the past decade, District (Figure 4). there has emerged a substantial body of research that tracks Hpatterns of international migration of health personnel, Figure 4: Shiselweni District, Swaziland 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 Piggs Peak the target of a ‘global raiding’ of skilled professionals by several devel- Hhohho Mhlume oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- MBABANE ernment. Siteki This paper aims to to examine policy debates and issues concerning Lobamba Manzini Lubombo the migration of skilled health professionals from the country and to Manzini Mankayane furnish new insights on the recruitment patterns of skilled health per- Big Bend sonnel. The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- Hlatikulu ment of skilled professionals from South Africa in the health Nhlangano sector. The paper draws upon a detailed analysis of recruitment Shiselweni advertising appearing in the South African Medical Journal for Lavumisa the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. • Based upon the above analysis and additional interviews with key stakeholders in the South African health sector, the paper The questionnaire was administered to a total of 50 working male offers a series of recommendations for addressing the problem of miners and 98 rural female partners in Swaziland and 40 miners and 80 skilled health migration. These recommendations are grounded rural partners in Mozambique. Snowball sampling techniques were used in both South African experience and an interrogation of inter- to identify interviewees. However, comparison with the more larger and national debates and ‘good policy’ practice for regulating recruit- more systematic SAMP sample in 2005 suggests that the miners are ment. broadly representative of their respective national cohorts. No such con- The paper is organized into five sections. Section Two positions trol group exists with regard to the rural partners. The generalizability debates about the migration of skilled health professionals within a of the findings, particularly with regard to partners, therefore need to be wider literature that discusses the international mobility of talent. carefully qualified. These are studies of a limited non-random sample. Section Three reviews research on the global circulation of health pro- The women interviewed were not the actual partners of the miners inter- fessionals, focusing in particular upon debates relating to the experience viewed. To interview both partners in a relationship was considered to of countries in the developing world. Section Four moves the focus from be less likely to elicit honest responses. In addition, the survey primarily international to South African issues and provides new empirical mate- posed questions about attitudes, perceptions, knowledge and behaviour. rial drawn from the survey of recruitment patterns and key interviews The results are likely to be more reliable about awareness and percep- undertaken with health sector recruiters operating in South Africa. tions of risk than self-reported sexual activity. 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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PErofileXECUTIVE of RSUMMARYespondents

ealth workers are one of the categories of skilled profession- Swaziland als most affected by globalization. Over the past decade, there has emerged a substantial body of research that tracks Hhepatterns majority of of international mineworkers migration interviewed of healthwere in personnel, their forties assesses causeswhile and the consequences,rural female partners and debates were mainlypolicy responsesin their thirties. at global and nationalBoth scales. groups Within were alsothis relativelyliterature, uneducated, the case of Souththe majority Africa not is attracting havinggrowing gone interest. beyond For primary almost school.15 years Nearly South three Africa quarters has been of Tmalethe target migrants of a were‘global married raiding’ (72%) of skilled and another professionals 10% wereby several co-habiting. devel- Onlyoped 2countries. of the miners How interviewedto deal with were the consequencessingle. Most migrant of the resultantminers there out-- foreflow haveof health long-term professionals relationships is a core with policy rural issuewomen. for Theythe national are not, gov- as theyernment. were in the past, young, single men. SwaziThis paper migrant aims miners to to earnexamine relatively policy low debates incomes. and Theissues average concerning wage ofthe respondents migration ofwas skilled only R2,000health professionalsper month.43 from The theamount country is small and butto stillfurnish higher new than insights the average on the recruitmentmonthly wage patterns in Swaziland. of skilled Almost health 80% per- ofsonnel. migrant-sending The objectives households of the paper had no are other twofold: source of income than the remittances• To provide sent home an audit by the of miners. the organization The money and is usedpatterns to support of recruit- very large families:ment of45% skilled of the professionals men interviewed from South support Africa between in the five health and nine children,sector. whileThe paper a further draws 22% upon support a detailed ten children analysis or of more. recruitment Only 5% had advertisingno children appearing to support. in The the majoritySouth African of mine Medical migrants Journal support for betweenthe one period and four 2000-2004 adults in and addition a series to of the interviews children. conductedThese are largewith families privateif we consider recruiting that enterprises. according to the Swaziland Census in 1997 the •average Based family upon size the in above the country analysis was and roughly additional five. interviews Clearly, the with AIDS epidemickey has stakeholders dramatically in increased the South the African number health of dependants sector, the supported paper by migrants.offers a series of recommendations for addressing the problem of The skilledmigrants health work migration.at several differentThese recommendations mines in South Africa, are grounded the majorityin at both West South Deep AfricanLevel and experience Vaal Reefs. and Most an interrogationhave worked ofin inter-the industrynational for more debates than eight and years,‘good whichpolicy’ is practice consistent for withregulating the general recruit- pattern ment.in the mining industry of a stable, but aging, workforce. Many are Themachine paper operators is organized (over into 40%), five withsections. the remainder Section Two being positions general labourersdebates about and drivers.the migration Swazi miners of skilled are healthgenerally professionals known for withintheir speciali a - zationwider literaturein operating that mine discusses machinery. the international The majority mobility of the mine of talent. migrants areSection accommodated Three reviews in single-sex research onmine the compounds. global circulation Some, however,of health pro- rentfessionals, accommodation focusing in in particular neighbouring upon communities. debates relating According to the experience to some informants,of countries this in the is especially developing true world. of migrants Section who Four have moves forged the extra-focus from maritalinternational relationships to South with African women issues in the and vicinity provides of thenew mine empirical irrespective mate- ofrial whether drawn fromthey havethe survey wives ofor recruitmentgirlfriends back patterns in Swaziland. and key interviews undertakenMost of the with Swazi health migrants sector returnrecruiters regularly operating to their in South rural homes.Africa. AroundSection 60%Five visitaddresses their thehomes questions in Swaziland of changing monthly, policy while interventions 30% said in theySouth do Africa so every towards other themonth. outflow This of was skilled corroborated health professionals by the rural and female the partners;recruitment just of over foreign half health(52%) saidprofessionals that they to see work their in husbands South Africa. monthly. The Regardless of the intervals between visits, the length of each visit home is

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EXECUTIVE SUMMARY usually short. The majority (around 60%) said that their home visits last for 1-2 days. Another 30% said that their visits typically last for 3-5 days. ealth workers are one of the categories of skilled profession- As many as 40% of the migrant mineworkers are sometimes visited by als most affected by globalization. Over the past decade, their partners at the mines. there has emerged a substantial body of research that tracks Hpatterns of international migration of health personnel, Mozambique assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is The Mozambican minerswere also relatively uneducated. Around 70% attracting growing interest. For almost 15 years South Africa has been had only completed primary schooling. Some 15% had not been to school the target of a ‘global raiding’ of skilled professionals by several devel- at all. Only one of the miners was single while the remainder were either oped countries. How to deal with the consequences of the resultant out- married (50%) or cohabitating (48%). More of the rural partners (61%) flow of health professionals is a core policy issue for the national gov- said they were co-habiting while only a third (32%) were formally married. ernment. Five of the partners were widows. All of the miners have large numbers of This paper aims to to examine policy debates and issues concerning dependants, with the average supporting nine other people. Of these, 5 the migration of skilled health professionals from the country and to are children and 4 are adults. Five of the miners said they had 15 or more furnish new insights on the recruitment patterns of skilled health per- dependants. sonnel. The objectives of the paper are twofold: Rural partners are heavily dependent on migrant miners for income. • To provide an audit of the organization and patterns of recruit- The majority (74%) said they earned less than 1,000,000 Mts per month ment of skilled professionals from South Africa in the health and therefore contribute little to household income (Table 6). Ninety sector. The paper draws upon a detailed analysis of recruitment percent listed their occupation as camponesa (rural agriculturalist). Most advertising appearing in the South African Medical Journal for miners earn over 3,000,000 Mts (135 USD) per month. These findings the period 2000-2004 and a series of interviews conducted with are confirmed by other studies on remittances which show that remit- private recruiting enterprises. ted funds and goods are integral to household income and survival in 44 • Based upon the above analysis and additional interviews with migrant-sending Mozambique. The death or disability of a miner there- key stakeholders in the South African health sector, the paper fore has very serious ramifications for the rural household. The number offers a series of recommendations for addressing the problem of of people affected will also be large, given the size of most mine migrant- skilled health migration. These recommendations are grounded sending households. in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- Table 6: Average Monthly Income for Miners and Partners ment. Income level (Mts) Male Miners Female Partners The paper is organized into five sections. Section Two positions No. % No. % debates about the migration of skilled health professionals within a Less than 500,000 (23 USD) 5 12 45 56 wider literature that discusses the international mobility of talent. 500,000 to 1,000,000 2 5 14 17 Section Three reviews research on the global circulation of health pro- 1,000,001 to 1,500,000 4 10 6 8 fessionals, focusing in particular upon debates relating to the experience 1,500,001 to 2,000,000 0 0 3 5 of countries in the developing world. Section Four moves the focus from 2,000,001 to 2,500,000 0 0 2 2 international to South African issues and provides new empirical mate- 2,500,001 to 3,000,000 3 8 1 1 rial drawn from the survey of recruitment patterns and key interviews More than 3,000,000 (135 USD) 24 60 2 2 undertaken with health sector recruiters operating in South Africa. Don’t know 2 5 7 9 Section Five addresses the questions of changing policy interventions in Total 40 100 80 100 South Africa towards the outflow of skilled health professionals and the 1 USD = 22,200 Mozambican Metical (2004 Monthly average) recruitment of foreign health professionals to work in South Africa. The

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EXECUTIVEConsistentSUMMARY with the findings from the 2005 SAMP survey, the migrants stay away from home for long periods and return home only for short annualealth vacations. workers In are the one average of the year, categories the migrant of skilled spends profession- 10-11 months a yearals awaymost fromaffected home by andglobalization. only rarely Over visits the during past thatdecade, time. Around three-quartersthere has emerged said they a substantialsee their partner body ofjust research once a thatyear tracksor even less frequently.patterns ofSome international 17% said themigration last visit of was health more personnel, than a year Hago. Only 24% had seen their partners in recent weeks. assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is Swazilandattracting Sur vgrowingey Finding interest.s For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- he reality of HIV and AIDS is well-recognized by both migrant flow of health professionals is a core policy issue for the national gov- mineworkers and rural partners. Both groups said that more ernment. people were dying in the home area than in previous years. This paper aims to to examine policy debates and issues concerning Some indicated that almost every weekend there were funerals; the migration of skilled health professionals from the country and to Tothers that funerals were often conducted simultaneously because of the furnish new insights on the recruitment patterns of skilled health per- number of deaths. A quarter of the respondents cited AIDS as the lead- sonnel. The objectives of the paper are twofold: ing cause of death of miners and ex-miners. Others cited occupational • To provide an audit of the organization and patterns of recruit- injury (22%), tuberculosis (19%) and other disease (19%). Only 2% cited ment of skilled professionals from South Africa in the health witchcraft and hunger. AIDS also stands out as the leading perceived sector. The paper draws upon a detailed analysis of recruitment cause of death of community members in general (31%). Other causes of advertising appearing in the South African Medical Journal for death mentioned included TB (20%), other diseases (21%), witchcraft the period 2000-2004 and a series of interviews conducted with (5%), heart attacks (4%) and old age (4%). private recruiting enterprises. A 2003 Survey concluded that “Swazi people are highly knowledge- • Based upon the above analysis and additional interviews with able about HIV/AIDS/STIs but this knowledge has not translated into key stakeholders in the South African health sector, the paper desirable behavioural change.”45 This study made a similar finding. All offers a series of recommendations for addressing the problem of respondents were very aware of HIV and AIDS. The majority of both skilled health migration. These recommendations are grounded migrants (68%) and rural female partners (67%) said they were aware in both South African experience and an interrogation of inter- that AIDS is not curable. Most also disagreed with common myths that a national debates and ‘good policy’ practice for regulating recruit- person can get infected through sharing a meal with an infected person, ment. sharing tools at work, sharing a bed, sharing clothes or shaking hands. The paper is organized into five sections. Section Two positions Reasonably high levels of awareness about protection were also demon- debates about the migration of skilled health professionals within a strated. Abstinence was viewed by over 60% of migrants and partners wider literature that discusses the international mobility of talent. as a main means of protection, which may have to do with messages Section Three reviews research on the global circulation of health pro- preached by the churches in Swaziland. fessionals, focusing in particular upon debates relating to the experience However, interesting differences about the efficacy of condoms of countries in the developing world. Section Four moves the focus from emerged between the two target groups (Figure 5). While over 80% of international to South African issues and provides new empirical mate- rural women saw condoms as an effective form of protection, the propor- rial drawn from the survey of recruitment patterns and key interviews tion of men was much lower (at 43%). While 20% of women said that undertaken with health sector recruiters operating in South Africa. avoiding blood transfusions was important, hardly any men mentioned Section Five addresses the questions of changing policy interventions in transfusions. On the other hand, nearly 10% of the miners saw the pro- South Africa towards the outflow of skilled health professionals and the tection of traditional healers as a viable means of prevention. Women recruitment of foreign health professionals to work in South Africa. The appear to have much less faith in traditional healers’ remedies. None cited this as a viable means of protection.

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EXECUTIVE SUMMARY Figure 5: Main Means of Protection Against HIV ealth workers are one of the categories of skilled profession- Avoid sharing razor blades als most affected by globalization. Over the past decade, Seek protection from traditional healers there has emerged a substantial body of research that tracks patterns of international migration of health personnel, Avoid blood transfusion Partners H Miners assesses causes and consequences, and debates policy responses at global Avoid sex with prostitutes and national scales. Within this literature, the case of South Africa is attracting growing interest. For almost 15 years South Africa has been Limit number of sex partners the target of a ‘global raiding’ of skilled professionals by several devel- Limit sex to one partner oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- Use condom ernment. This paper aims to to examine policy debates and issues concerning Abstain from sex the migration of skilled health professionals from the country and to 0 10 20 30 40 50 60 70 80 90 furnish new insights on the recruitment patterns of skilled health per- Percentage sonnel. The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- Note: More than one answer permitted. ment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment Self-assessment of risk showed that more women than men felt they advertising appearing in the South African Medical Journal for were at risk of HIV infection (Figure 6). Nearly 80% of miners felt that the period 2000-2004 and a series of interviews conducted with they were at low or no risk at all and only 15% thought they were at fig 7 bar graph.pdf 1 26/11/2010 2:07 PM private recruiting enterprises. high risk. Most workers who said they were at low risk noted that it was • Based upon the above analysis and additional interviews with because they were faithful to their partners, even though the responses to key stakeholders in the South African health sector, the paper other questions contradicted this assertion. Those who said they were at offers a series of recommendations for addressing the problem of high risk blamed their partners: they felt that they could not trust their skilled health migration. These recommendations are grounded partners and believed they were unfaithful. in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- Figure 6: Self-Assessment of Risk of Infection ment. The paper is organized into five sections. Section Two positions I am at high risk debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. I am at a slight/small risk Section Three reviews research on the global circulation of health pro- Not at risk at all fessionals, focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from Refused to answer Partners international to South African issues and provides new empirical mate- Miners rial drawn from the survey of recruitment patterns and key interviews Don’t know undertaken with health sector recruiters operating in South Africa. 0 10 20 30 40 50 60 Section Five addresses the questions of changing policy interventions in Percentage 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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EXECUTIVEInS dramaticUMMARY contrast, rural partners were much more pessimistic about their risk of infection. Over half (51%) felt that they were at high risk and only 8%ealth said workersthere was are no one risk of at the all. categories Women’s ofsense skilled of vulnerability profession- came from theals mostperceived affected behaviour by globalization. of their partners, Over the not past their decade, own. Most of the womenthere who has felt emerged they were a substantial at high risk body felt thisof research way because that tracks their partners engagedpatterns in high-riskof international sex with migration others. Nearly of health half personnel,(48%) said Htheir migrant partners were not faithful and/or did not want to use con- assesses causes and consequences, and debates policy responses at global doms.and national Another scales. 22% Withinsaid that this they literature, were at riskthe becausecase of Souththey had Africa no ideais aboutattracting their growing partners’ interest. sexual activityFor almost while 15 away years from South home. Africa A hasfurther been 12%the target said they of a did‘global not raiding’trust their of partner.skilled professionals In other words, by severalover 80% devel- of the womenoped countries. who said How they towere deal at with high the risk consequences blamed their migrantof the resultant partners out- for theirflow ofown health vulnerability. professionals If the is migrantsa core policy are to issue be believed, for the national these fears gov- are groundless.ernment. The lack of trust amongst miners and partners dominate the feelingsThis ofpaper those aims who to consider to examine themselves policy debatesat high andrisk andissues raises concerning impor- tantthe migrationconcerns aboutof skilled the healthpsychological professionals stresses from that the migration country puts and on to inter-personalfurnish new insights relationships. on the recruitment patterns of skilled health personnel.In light The of objectives the fundamentally of the paper different are twofold: risk perceptions of mine migrants• To and provide rural womenan audit and of thethe organizationapparently high and levels patterns of mistrust of recruit- betweenment them, of the skilled survey professionals sought to gainfrom some South insights Africa into in the actual health risk taking behaviour.sector. The The paper migrants draws exhibitedupon a detailed a strong analysis inclination of recruitment for multiple sexualadvertising partnerships appearing (Figure in 7). the Only South 7% Africansaid they Medical had had Journal only one for lifetime thepartner. period Another 2000-2004 30% andsaid athey series had of hadinterviews sex with conducted between 2with and 5 womenprivate and 33% recruiting with between enterprises. 6 and 10 women. Twenty two percent had• had Basedmore uponthan 10the partners. above analysis These findingsand additional are not interviews inconsistent with with otherkey studies stakeholders of the sexualin the Southpractices African of migrant health miners sector, in the Southern paper Africa.46offers In sharp a series contrast, of recommendations 35% of female partners for addressing said they the had problem had one of lifetime skilledsexual partnerhealth migration. and a further These 32% recommendations only two. Just 14% are said grounded they had 5 orin more both partners South African and only experience 3% had had and 10 an or interrogation more. The women of inter- said thatnational having multipledebates andpartners ‘good is policy’ not that practice common for inregulating rural areas. recruit- The ment.primary anomaly is that migrant miners do not generally view themselvesThe paper as ais highorganized risk group, into fiveyet havesections. multiple Section sexual Two partners. positions Givendebates their about awareness the migration of HIV of and skilled AIDS, health this professionalsmight imply thatwithin they a takewider adequate literature precautionary that discusses measures. the international Such a hypothesis mobility ofshould, talent. at the verySection least, Three translate reviews into research high levels on theof condom global circulation use. In fact, of nearly health three pro- quartersfessionals, of focusingthose who in hadparticular had sex upon in the debates previous relating 30 days to thehad experience not used a condom.of countries Asked in the why, developing the majority world. responded Section either Four thatmoves they the did focus not fromlike theminternational (37%), had to South forgotten African to use issues them and (20%) provides or did new not empirical think they mate- were necessaryrial drawn (17%) from the(Figure survey 8). of In recruitment general, however, patterns these and migrant key interviews miners do notundertaken appear to with have health a good sector sense recruiters of the heightened operating riskin South of having Africa. unpro- tectedSection sex Five with addresses multiple the partners. 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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fig 8 bar graph vert.pdf 1 02/02/2011 10:58 AM

EXECUTIVE SUMMARY Figure 7: Number of Lifetime Sexual Partners 40 – ealth workers are one of the categories of skilled profession- Partners als most affected by globalization. Over the past decade, 35 – Miners there has emerged a substantial body of research that tracks 30 – Hpatterns of international migration of health personnel, assesses causes and consequences, and debates policy responses at global 25 – and national scales. Within this literature, the case of South Africa is attracting growing interest. For almost 15 years South Africa has been 20 – Percentage the target of a ‘global raiding’ of skilled professionals by several devel- 15 – oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- 10 – fig 9 bar graph horiz.pdf 1 29/11/2010 1:18 PM ernment. 5 – This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to 0 – 1 2 3 4 5 6 7 8 9 10 >10 Don’t furnish new insights on the recruitment patterns of skilled health per- know sonnel. The objectives of the paper are twofold: • To provide an audit of the organization and patterns of recruit- Figure 8: Reason for Not Using Condom During Last Sexual Act ment of skilled professionals from South Africa in the health sector. The paper draws upon a detailed analysis of recruitment Not available advertising appearing in the South African Medical Journal for Partner objected the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. Didn't think of it • Based upon the above analysis and additional interviews with Partners Miners key stakeholders in the South African health sector, the paper Not necessary offers a series of recommendations for addressing the problem of Don’t like them skilled health migration. These recommendations are grounded Other in both South African experience and an interrogation of international debates and ‘good policy’ practice for regulating recruit- 0 10 20 30 40 50 60 ment. Percentage The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a A different pattern emerges with rural partners. Condom use is as low wider literature that discusses the international mobility of talent. as that of the male migrants: 79% had not used a condom during their Section Three reviews research on the global circulation of health pro- last sexual act. However, unlike their male counterparts, this had very fessionals, focusing in particular upon debates relating to the experience little to do with a dislike of condoms (only 14% versus 37% of men), of countries in the developing world. Section Four moves the focus from though some did forget (6%) or think it unnecessary (17%). What is international to South African issues and provides new empirical mate- most striking is that 53% did not use condoms because their partners rial drawn from the survey of recruitment patterns and key interviews objected to their use. In other words, while rural partners in mine- undertaken with health sector recruiters operating in South Africa. sending areas protect themselves through limiting the number of sexual Section Five addresses the questions of changing policy interventions in partners, this does not render them invulnerable to infection because South Africa towards the outflow of skilled health professionals and the condom use is so low. This increased vulnerability is rooted in gender recruitment of foreign health professionals to work in South Africa. The relations of inequality with partners who reject condom use while simultaneously engaging in high risk sexual behaviour themselves at the mines.

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EXECUTIVEUnequalSUMMARY gender relations, the relative lack of power of women, women’s status and gender-based violence have all been advanced to explain the vulnerabilityealth ofworkers migrant are and one non-migrant of the categories women of inskilled Swaziland. profession-47 UNDP’s genderals most analysis affected of the by Swaziland globalization. epidemic Over concluded:the past decade, Women’sthere vulnerability has emerged to a HIVsubstantial infection body is increasedof research by that eco -tracks Hnomic,patterns social andof international cultural factors migration and by ofdifferent health formspersonnel, of assessesviolence causes and(particularly consequences, sexual), and that debates place policythem at responses a disadvan at -global and nationaltage within scales. relationships, Within this the literature, family, thethe economycase of South and soci Africa- is attractingety atgrowing large. Women’sinterest. Foreconomic almost dependence 15 years South on men,Africa their has been the targethigh of poverty a ‘global levels raiding’ and lackof skilled of access professionals to opportunities by several and developed countries.resources, Howcontribute to deal to with their the vulnerability consequences to HIV of the infection. resultant outflow ofBecause health professionalsof the economic is a dependencecore policy issueon men, for thewomen national are government.unable to take control of their lives and protect themselves Thisagainst paper HIV aims infection. to to examine48 policy debates and issues concerning the migration of skilled health professionals from the country and to furnishThe newreport insights also observes on the thatrecruitment women inpatterns Swaziland of skilled are expected health per-by mensonnel. to beThe subordinate objectives andof the submissive, paper are that twofold: it is considered acceptable for men• to have To provide multiple an sexualaudit ofpartners, the organization and that certainand patterns practices of recruit-(such as polygamy,ment arranged of skilled marriage, professionals widow inheritancefrom South andAfrica the in reed the dance) health all contributesector. to the The spread paper of draws HIV. uponThe vulnerability a detailed analysis of women of recruitment is explicitly 49 acknowledgedadvertising by the appearing Swaziland in government.the South African However, Medical “there Journal is no for leg- 50 islation thein place period to 2000-2004protect the andbasic a rightsseries of women.”interviews conductedIn other words, with while migrancyprivate recruitingputs many enterprises.Swazi men at risk, it is gender relations within Swaziland• Based that upon heightens the above the vulnerability analysis and of additional most women. interviews When with high- risk malekey migration stakeholders is combined in the Southwith gender African inequality health sector, in migrant-send the paper - ing areas,offers the arisk series for women,of recommendations particularly spouses for addressing and partners the problem (regular of and casual),skilled is magnified.health migration. If women These were recommendations empowered to make are theirgrounded own decisionsin about both sexualSouth Africanbehaviour experience and protection, and an the interrogation impact of high-risk of inter- behaviournational by migrant debates men and would ‘good be policy’ accordingly practice reduced. for regulating recruitment. The paper is organized into five sections. Section Two positions Mozambique Survey Findings debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. nowledge of the existence of HIV and AIDS is reasonably Section Three reviews research on the global circulation of health pro- high amongst Mozambican miners. However, as many as 60% fessionals, focusing in particular upon debates relating to the experience thought that AIDS was curable. Of these, 22% claimed that of countries in the developing world. Section Four moves the focus from modern medicine held a cure and 15% cited traditional medi- international to South African issues and provides new empirical mate- Kcine. A higher proportion of rural partners know that AIDS is incurable rial drawn from the survey of recruitment patterns and key interviews (61% compared to 40% of miners). Knowledge that unprotected sex was undertaken with health sector recruiters operating in South Africa. the major means of transmission was also far from universal (60% of min- Section Five addresses the questions of changing policy interventions in ers, again lower than the rural partners at 69%) (Figure 9). Knowledge of South Africa towards the outflow of skilled health professionals and the the importance of using condoms as protection against HIV was higher recruitment of foreign health professionals to work in South Africa. The (Figure 10). In theory, given the existence of HIV and AIDS education pro-

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EXECUTIVE SUMMARY grammes on the mines, miners ought to be better informed about HIV and AIDS than their Mozambican partners. In fact, rural women were ealth workers are one of the categories of skilled profession- slightly better informed about the risks. Nearly 30% of women saw fidel- als most affected by globalization. Over the past decade, ity as a means of protection compared with only 12% of men. However, a there has emerged a substantial body of research that tracks third of the men said that avoiding sex with commercial sex workers was patterns of international migration of health personnel, important, which indicates some awareness of the risks associated with H transactional sex. assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is fig 10 bar graph horiz.pdf 1 29/11/2010 1:29 PM attracting growing interest. For almost 15 years South Africa has been Figure 9: Perceived Methods of Contracting HIV/AIDS the target of a ‘global raiding’ of skilled professionals by several developed countries. How to deal with the consequences of the resultant out- Shaking hands flow of health professionals is a core policy issue for the national gov- Sharing clothes ernment. Sharing a bed This paper aims to to examine policy debates and issues concerning the migration of skilled health professionals from the country and to Having sex without condom furnish new insights on the recruitment patterns of skilled health per- Touching someone else’s blood sonnel. The objectives of the paper are twofold: Having sexual intercourse Partners • To provide an audit of the organization and patterns of recruit- Miners ment of skilled professionals from South Africa in the health From being bewitched sector. The paper draws upon a detailed analysis of recruitment Injections with used needle advertising appearing in the South African Medical Journal for Sharing tools with infected individual at work the period 2000-2004 and a series of interviews conducted with private recruiting enterprises. Sharing a meal with infected individual • Based upon the above analysis and additional interviews with 0 10 20 30 40 50 60 70 80 90 100 fig 11 bar graph horiz.pdf 1 29/11/2010 1:36 PM key stakeholders in the South African health sector, the paper Percentage 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 inter- Figure 10: Means of Protection from HIV national debates and ‘good policy’ practice for regulating recruitment. Avoid sharing razor blades The paper is organized into five sections. Section Two positions Seek protection from traditional healer debates about the migration of skilled health professionals within a wider literature that discusses the international mobility of talent. Avoid blood transfusions Section Three reviews research on the global circulation of health pro- Avoid sex with prostitutes Partners fessionals, focusing in particular upon debates relating to the experience Miners of countries in the developing world. Section Four moves the focus from Limit number of sex partners international to South African issues and provides new empirical mate- Limit sex to one partner rial drawn from the survey of recruitment patterns and key interviews Use condoms undertaken with health sector recruiters operating in South Africa. Section Five addresses the questions of changing policy interventions in Abstaining from sex South Africa towards the outflow of skilled health professionals and the 0 10 20 30 40 50 60 70 80 90 100 recruitment of foreign health professionals to work in South Africa. The Percentage

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EXECUTIVEWhenSUMMARY asked to identify the symptoms associated with HIV and AIDS, there were distinct differences between the levels of knowledge and understanding exhibitedealth workers by miners are and one rural of the partners. categories Less of than skilled a third profession- of the miners wereals able most to identify affected any by symptomsglobalization. associated Over thewith past HIV decade, and AIDS. The symptomsthere identified has emerged by the a others substantial were non-specificbody of research and could that tracksreflect almost any commonpatterns disease:of international cough, loss migration of weight of or health appetite personnel, and fever. HThe rural partners fared somewhat better on this question although as assesses causes and consequences, and debates policy responses at global manyand national as half admittedscales. Within they did this not literature, know any the of case the symptomsof South Africa of HIV is andattracting AIDS. growing The most interest. commonly For almostlisted symptoms 15 years South listed Africaby the partnershas been werethe target diarrhea, of a skin‘global boils raiding’ or lesions, of skilled weight professionals loss, recurrent by several vomiting devel- and hairoped loss. countries. Many ofHow the tospouses deal with listed the multiple consequences symptoms, of the often resultant three or out- moreflow ofper health respondent. professionals The distinction is a core policy between issue miners for the and national their spouses gov- isernment. dramatic and may be because residents of Chokwe are far more likely to encounterThis paper people aims towith to examineAIDS on policy a daily debates basis.51 and issues concerning theAIDS migration was cited of skilled as the health major professionals cause of mortality from thein the country home and districts to byfurnish rural newpartners insights (Figure on the11). recruitment Personal exposure patterns to of people skilled with health AIDS per- issonnel. clearly The a factor objectives in raising of the awareness paper are and twofold: understanding of HIV and AIDS.• Only To provide a small an number audit ofof theminers organization admitted andhaving patterns a close of friend recruit- liv- ing withment HIV ofand skilled AIDS, professionals and only one from said South they knewAfrica of in a theclose health relative with thesector. disease. The Only paper a quarter draws uponof the a miners detailed acknowledged analysis of recruitment that they knew someoneadvertising with appearing AIDS. More in the of theSouth partners African knew Medical someone Journal living for with HIVthe and period AIDS. 2000-2004 They were and more a series likely of to interviews know of aconducted close relative with figwith 12 bar the graphprivate disease horiz.pdf recruiting than a1 close enterprises.29/11/2010 friend. Nine2:01 PM percent had a close friend, and 13%• had Based a close upon relative, the above with HIVanalysis or AIDS.and additional interviews with key stakeholders in the South African health sector, the paper Figure 11: Main Causesoffers of Deatha series in Homeof recommendations Communities (Partners) for addressing the problem of AIDS skilled health migration. These recommendations are grounded in both South African experience and an interrogation of inter- Tuberculosis national debates and ‘good policy’ practice for regulating recruit- Diarrhea ment. Other diseases/illnessesThe paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a Malaria wider literature that discusses the international mobility of talent. Heart attackSection Three reviews research on the global circulation of health pro- Occupationalfessionals, injury focusing in particular upon debates relating to the experience of countries in the developing world. Section Four moves the focus from Hunger international to South African issues and provides new empirical mate- Old age rial drawn from the survey of recruitment patterns and key interviews Accidents undertaken with health sector recruiters operating in South Africa.

Murder Section Five addresses the questions of changing policy interventions in South Africa towards the outflow of skilled health professionals and the Witchcraft recruitment of foreign health professionals to work in South Africa. The 0 10 20 30 40 50 60 70 80 90 100 Percentage 231 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk MIGRATION POLICY SERIES NO. 45 Migration-Induced HIV and AIDS in Rural Mozambique and Swaziland

EXECUTIVE SUMMARY Most (90%) miners said that they felt that HIV and AIDS was a problem at the mines and that they worry about the disease a lot. Three- ealth workers are one of the categories of skilled profession- quarters felt they were at high risk of becoming infected and only three als most affected by globalization. Over the past decade, of the respondents felt they were not at risk. At the same time, not all there has emerged a substantial body of research that tracks miners had taken active measures to ascertain their own status. Less patterns of international migration of health personnel, than a third of the miners had ever been tested for HIV (30%) and just H over half of those (17% of total) had voluntarily sought testing. The vast assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is majority of the female partners also said they worry about HIV/AIDS attracting growing interest. For almost 15 years South Africa has been a lot (93%) and 94% agreed that it was a problem in the community. the target of a ‘global raiding’ of skilled professionals by several devel- Three-quarters felt that they are at high risk of becoming infected with oped countries. How to deal with the consequences of the resultant out- the disease. Only one individual felt she was at no risk at all. Yet, few flow of health professionals is a core policy issue for the national gov- partners had actually sought out an HIV test; only 16% of the women ernment. had been tested, all voluntarily. This paper aims to to examine policy debates and issues concerning The pursuit of a stable and enduring relationship is extremely difficult the migration of skilled health professionals from the country and to under circumstances of prolonged separation. All of those interviewed furnish new insights on the recruitment patterns of skilled health per- reported having at least one sexual partner in their lifetime, and many sonnel. The objectives of the paper are twofold: reported multiple partners. All but one of the miners said they were cur- • To provide an audit of the organization and patterns of recruit- rently sexually active, not all with regular partners. Nearly 40% of the ment of skilled professionals from South Africa in the health miners said they had engaged in sexual relations with someone who was sector. The paper draws upon a detailed analysis of recruitment not their spouse or primary partner in the previous 12 months. Forty advertising appearing in the South African Medical Journal for three percent of this group said they had had sex with women who the period 2000-2004 and a series of interviews conducted with requested money or goods in exchange. The frequency of these encoun- private recruiting enterprises. ters ranged from once to six times per year. • Based upon the above analysis and additional interviews with Despite the fact that the majority of both miners and partners view key stakeholders in the South African health sector, the paper themselves as at risk of contracting HIV and know that condom use is offers a series of recommendations for addressing the problem of the primary means of protection, actual use of condoms is sporadic and skilled health migration. These recommendations are grounded low. None of the miners said they always or almost always used a condom in both South African experience and an interrogation of inter- during sex. Even those that did use condoms did not use them every time national debates and ‘good policy’ practice for regulating recruit- they have sex. One miner said he had used a condom only once during ment. the previous month and yet had 10 sexual encounters with his regular The paper is organized into five sections. Section Two positions partner. Another had used a condom for only 4 of his 22 encounters dur- debates about the migration of skilled health professionals within a ing the last month. When asked why they did not use condoms all the wider literature that discusses the international mobility of talent. time, the largest number (38%) said they did not like them, while 25% Section Three reviews research on the global circulation of health pro- said that they simply forgot. Another 15% did not think condom use was fessionals, focusing in particular upon debates relating to the experience necessary. None of the miners said that access or cost was a deterrent to of countries in the developing world. Section Four moves the focus from using condoms (Table 8). international to South African issues and provides new empirical mate- In other words, most Mozambican miners are at risk, know they are at rial drawn from the survey of recruitment patterns and key interviews risk, know how to reduce the risk, yet do not take precautions to reduce undertaken with health sector recruiters operating in South Africa. that risk. This paradox has been pointed out by previous researchers.52 Section Five addresses the questions of changing policy interventions in Condoms are freely available and their efficacy is recognized. Yet there is South Africa towards the outflow of skilled health professionals and the clearly not a culture of condom use amongst miners. The stated reasons recruitment of foreign health professionals to work in South Africa. The given for non-use relate primarily to personal taste and forgetfulness. Campbell also concluded that migrant mine workers display “continued

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EXECUTIVEcommitmentSUMMARY to a macho notion of masculinity that undermined the likelihood of condom use…Several miners commented that the condoms provided by ealththe mines workers could are notone be of trustedthe categories because of they skilled were profession- of a poor quality and alshad most often affected passed bytheir globalization. ‘use by’ dates. Over Some the suggested past decade, that it was these verythere condoms has emerged that were a substantial causing the body HIV of infection.”research that53 tracks Hpatterns of international migration of health personnel, Table 7: Reasonsassesses for causes Not Using and Condoms consequences, and debates policy responses at global and national scales. Within this literature, the caseNo. of South Africa% is Not availableattracting growing interest. For almost 15 years South0 Africa has been0 Too expensivethe target of a ‘global raiding’ of skilled professionals0 by several devel-0 Partner objectedoped countries. How to deal with the consequences 3of the resultant7.5 out- Don’t like themflow of health professionals is a core policy issue for15 the national37.5 gov- Used anotherernment. form of contraceptive 3 7.5 Didn’t think it wasThis necessary paper aims to to examine policy debates and6 issues concerning15 Didn’t thinkthe about migration it of skilled health professionals from the9 country and22.5 to furnish new insights on the recruitment patterns of skilled health per- Other 1 2.5 sonnel. The objectives of the paper are twofold: Note: Multiple responses were allowed • To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health As argued above, the infrequency of home return of Mozambican sector. The paper draws upon a detailed analysis of recruitment miners considerably reduces the risk that rural partners will contract advertising appearing in the South African Medical Journal for the virus from their HIV positive migrant spouses or partners. That the period 2000-2004 and a series of interviews conducted with risk would be reduced still further if miners acted on their belief in the private recruiting enterprises. protective value of condoms when having sexual relations with their • Based upon the above analysis and additional interviews with partners at home. All the miners interviewed said they engage in sexual key stakeholders in the South African health sector, the paper activities with their regular partners. However, the majority reported not offers a series of recommendations for addressing the problem of using condoms with their partners. Most miners (80%) had not used skilled health migration. These recommendations are grounded a condom at all with their regular partner at any point in the previous in both South African experience and an interrogation of inter- year. Sixty five percent said they had not used condoms with their regu- national debates and ‘good policy’ practice for regulating recruit- lar partner over the past month. None of the miners said they always or ment. almost always use a condom with their partners. The paper is organized into five sections. Section Two positions The responses of rural partners confirmed this finding. None of the debates about the migration of skilled health professionals within a women had used a condom for every sexual encounter in the previ- wider literature that discusses the international mobility of talent. ous year and only 8% said they had used condoms every time they had Section Three reviews research on the global circulation of health pro- intercourse. Fifty five percent said they had not used condoms at all over fessionals, focusing in particular upon debates relating to the experience the previous year. Eighty-five percent of the women who had sex in the of countries in the developing world. Section Four moves the focus from month prior to the interview had not used a condom. When asked about international to South African issues and provides new empirical mate- low condom use, just under half (46%) responded that their partners rial drawn from the survey of recruitment patterns and key interviews objected to condom use. A further 10% said that they did not want their undertaken with health sector recruiters operating in South Africa. partners to think they were infected with HIV. Approximately half of the Section Five addresses the questions of changing policy interventions in respondents said they would have chosen to use condoms but did not feel South Africa towards the outflow of skilled health professionals and the they had that option. Those that did use them did so sporadically. Usage recruitment of foreign health professionals to work in South Africa. The is low primarily because female partners lack the power to effectively negotiate condom use.

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EXECUTIVE SUMMARY By their own admission, many of the partners of Mozambican mine migrants have other relationships when their partners are away at the ealth workers are one of the categories of skilled profession- mines. Given the fact that most rural women rarely see their migrant als most affected by globalization. Over the past decade, partners, the potential for other relationships to develop is high. Nearly there has emerged a substantial body of research that tracks one in five respondents said they had sex during this period with some- patterns of international migration of health personnel, one who was not their primary partner or spouse and where no financial H transaction took place. In addition, women are highly dependent on the assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is remittances sent home by their partners. As such, they remain very vul- attracting growing interest. For almost 15 years South Africa has been nerable to the remitting behaviour of their partner. If the remittances are the target of a ‘global raiding’ of skilled professionals by several devel- irregular or insufficient, household poverty deepens. Resorting to selling oped countries. How to deal with the consequences of the resultant out- sex for cash or goods is a not uncommon response. In the twelve months flow of health professionals is a core policy issue for the national gov- prior to the interview, 14% admitted having had sex in exchange for ernment. goods or money. This paper aims to to examine policy debates and issues concerning Of the 46 women who admitted having sexual relationships other the migration of skilled health professionals from the country and to than with their regular partner (57% of the total sample), just over furnish new insights on the recruitment patterns of skilled health per- 35% gave sexual satisfaction and emotional support as the primary rea- sonnel. The objectives of the paper are twofold: son while another 33% cited financial reasons and support for children • To provide an audit of the organization and patterns of recruit- (Figure 12). Condom use was no more consistent with non-regular part- ment of skilled professionals from South Africa in the health ners, suggesting that women’s power to negotiate safe sex is no stronger sector. The paper draws upon a detailed analysis of recruitment with casual than regular partners. The responses of partners in rural advertising appearing in the South African Medical Journal for Mozambique suggest that vulnerability in the mine-sending areas is not the period 2000-2004 and a series of interviews conducted with figsimply 13 bar agraph function horiz.pdf of the 1 exposure 29/11/2010 of 2:07female PM partners to HIV through private recruiting enterprises. returning migrant partners. • Based upon the above analysis and additional interviews with key stakeholders in the South African health sector, the paper Figure 12: Women’s Reasons for Having Other Partners offers a series of recommendations for addressing the problem of skilled health migration. These recommendations are grounded Somewhere to stay in both South African experience and an interrogation of inter- Support for children national debates and ‘good policy’ practice for regulating recruitment. Emotional support The paper is organized into five sections. Section Two positions Sexual satisfaction debates about the migration of skilled health professionals within a Financial Support wider literature that discusses the international mobility of talent. Section Three reviews research on the global circulation of health pro- Did Not Answer fessionals, focusing in particular upon debates relating to the experience Other of countries in the developing world. Section Four moves the focus from 0 5 10 15 20 25 international to South African issues and provides new empirical mate- Percentage rial 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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CEXECUTIVEonclusionSUMMARY

ollinsealth argues workers that are “donors one of [andthe categories others] have of skilled ignored profession- a key structuralals most affectedreason why by globalization.HIV continues Over to spread the past in Mozambiquedecade, – thereand elsewhere has emerged in Southern a substantial Africa body – today: of research the continuation that tracks ofpatterns the region-wide, of international low-wage migration migrant of labour health system. personnel, This sys- CHtem continues to fragment family life, thus helping sustain Mozambique’s assesses causes and consequences, and debates policy responses at global –and and national Southern scales. Africa’s Within – HIV this pandemic. literature, If the donors case andof South African Africa govern is - mentsattracting are seriousgrowing about interest. stemming For almost the rising 15 years tide Southof HIV, Africa they musthas been begin tothe explore target oflong-term a ‘global alternatives raiding’ of skilledto this migrantprofessionals labour by system several – devel-and tooped the countries. dominant How export-led to deal development with the consequences model on which of the this resultant system out-is 54 premised.”flow of health The professionals findings of isthis a core study policy support issue the for relevance the national of Collins’ gov- observationernment. and confirm that rural migrant-sending areas have become high-riskThis paper zones aimsfor HIV to to infection examine for policy women. debates and issues concerning theMigrant migration miners of skilled are long-term, health professionals career workers. from Asthe long country as their and health to holdsfurnish and new their insights mine ondoes the not recruitment close, they patterns keep their of skilledjobs. Age health and per-expe- riencesonnel. do The not objectives appear to ofhave the had paper any are significant twofold: mitigating impact on their• high To risk provide behavior. an audit While of the organizationevidence collected and patterns here relies of recruit- on self- reporting,ment many of minersskilled professionalsnot only have from additional South regularAfrica inpartners the health when they aresector. at work The but paper frequent draws contact upon awith detailed commercial analysis sex-workers of recruitment at hotspotsadvertising around the appearing mines. The in impactthe South of extended African Medicalseparation Journal and the for high-riskthe living period and 2000-2004 working environment and a series thatof interviews has always conducted characterized with the mines,private continues recruiting to facilitate, enterprises. if not encourage, high-risk behaviours that• greatly Based increase upon the the abovechances analysis of HIV and infection. additional interviews with Knowledgekey stakeholders of HIV and in AIDS the South is reasonably African goodhealth amongst sector, theresidents paper of these offerstwo traditional a series of minerecommendations migrant-sending for areasaddressing in Swaziland the problem and of Mozambique.skilled Many health of migration. the common These myths recommendations about HIV are heldare grounded by only a tiny minority.in both MostSouth seem African to know experience what puts and them an interrogation at risk, know of that inter- the diseasenational is fatal, debates know andthat ‘good ART policy’is not a practice remedy forand regulating do not appear recruit- to have ment.a great deal of faith in traditional healers. One exception is the ratherThe large paper proportion is organized of Mozambican into five sections. miners Section who believe Two positionsthe disease is curable.debates aboutIf anything, the migration rural partners of skilled are betterhealth informed professionals than withinminers awhich mustwider say literature something that about discusses the efficacythe international of mine education mobility programmes.of talent. In bothSection Mozambique Three reviews and Swaziland,research on the the main global source circulation of knowledge of health is not pro- workplacefessionals, programmesfocusing in particular on the mines upon or debates in the communityrelating to thenor experiencepeer edu- cationof countries nor the in medicalthe developing community, world. but Section radio. ThisFour could moves be the seen focus as anfrom additionalinternational indictment to South of African conventional issues andworkplace provides and new community-based empirical mate- educationrial drawn programmes.from the survey On ofthe recruitment other hand, patterns it demonstrates and key interviewsthe critical importanceundertaken andwith potential health sector of radio recruiters as the mediumoperating for in education. South Africa. SectionPerception Five addresses of personal the vulnerability questions of is changing high. Yet, policy both minersinterventions and in femaleSouth Africarural partners towards of the migrants outflow appear of skilled to place health themselves professionals at risk and the throughrecruitment their of behaviour. foreign health The reasonsprofessionals are, however, to work quitein South different. Africa. In The the case of miners at work, high risk behaviour is a consequence of the

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EXECUTIVE SUMMARY migrant labour system which sees them spend the greater part of the working year away from home in an all-male environment of macho mas- ealth workers are one of the categories of skilled profession- culinity with easy access to transactional sex.55 These miners certainly als most affected by globalization. Over the past decade, know that condom use would reduce their risk of contracting HIV but there has emerged a substantial body of research that tracks actual use is sporadic to non-existent. Condom use is rejected on grounds patterns of international migration of health personnel, of personal preference or attributed to forgetfulness. H Condom use does not seem to be a very effective means of reducing assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is risk in rural sending areas either as condom use is low there. Miners at attracting growing interest. For almost 15 years South Africa has been home are even less likely to use condoms than when on the mine. This the target of a ‘global raiding’ of skilled professionals by several devel- does not appear to be related to unavailability. None of the informants oped countries. How to deal with the consequences of the resultant out- mentioned this as an obstacle to use. The risks of contracting HIV are flow of health professionals is a core policy issue for the national gov- certainly lower (since commercial sex workers on the mines exhibit much ernment. higher HIV prevalence than rural partners). But their very unwillingness This paper aims to to examine policy debates and issues concerning to use protection puts their rural partners at greatly increased risk. the migration of skilled health professionals from the country and to While migrant men give “pragmatic” reasons related to sexual pleas- furnish new insights on the recruitment patterns of skilled health per- ure, necessity and forgetfulness, rural partners’ answers are lodged in sonnel. The objectives of the paper are twofold: the dynamics of gender inequality. Women’s lack of use of condoms has • To provide an audit of the organization and patterns of recruit- virtually nothing to do with personal preference. Partners of migrant ment of skilled professionals from South Africa in the health miners wish to use condoms. Their inability to do so with the frequency sector. The paper draws upon a detailed analysis of recruitment and consistency that they would like is related to the preferences and advertising appearing in the South African Medical Journal for demands of men. Any woman who insists on condom use is seen to be the period 2000-2004 and a series of interviews conducted with implicitly questioning her partner’s fidelity. Miners clearly expect their private recruiting enterprises. partners to be faithful and do not see themselves at risk when they go • Based upon the above analysis and additional interviews with home. This combination makes regular and consistent condom use key stakeholders in the South African health sector, the paper extremely unlikely as women lack the power to insist on condom use. offers a series of recommendations for addressing the problem of Ultimately, therefore, it is the gendered relations of inequality that make skilled health migration. These recommendations are grounded it very difficult for women to protect themselves. in both South African experience and an interrogation of inter- One interesting contrast is that Mozambican miners recognize that national debates and ‘good policy’ practice for regulating recruit- they are at high risk of infection while Swazi miners do not. Three quar- ment. ters of Mozambican miners thought they were at “high risk” of infection The paper is organized into five sections. Section Two positions compared to only 15% of Swazi miners. Since, by any objective criterion, debates about the migration of skilled health professionals within a they are, in fact, equally vulnerable, the real question is why so many wider literature that discusses the international mobility of talent. Swazi miners underestimate the risk. If Swazi mine workers consistently Section Three reviews research on the global circulation of health pro- used condoms, and Mozambican miners did not, this might explain the fessionals, focusing in particular upon debates relating to the experience different perceptions of vulnerability. Yet the two groups of miners were of countries in the developing world. Section Four moves the focus from equally uncommitted to regular and consistent condom use. While only a international to South African issues and provides new empirical mate- few did not use them at all, none of the miners used condoms every time rial drawn from the survey of recruitment patterns and key interviews they had sexual intercourse. Over 80% of Mozambican miners believe undertaken with health sector recruiters operating in South Africa. that condoms were an effective form of protection against HIV, compared Section Five addresses the questions of changing policy interventions in with only 40% of Swazi miners. Yet the latter did not give this as a reason South Africa towards the outflow of skilled health professionals and the for not using condoms. The reasons given by both groups were familiar, recruitment of foreign health professionals to work in South Africa. The and not unlike the reasons that men generally in this region give for not using condoms: they simply did not like them (nearly 40% of both

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EXECUTIVEMozambicansSUMMARY and Swazis), they forget (25% of Mozambicans and 28% of Swazis) or they really do not think they are necessary (17% of Swazis and 17% of Mozambicans).ealth workers are one of the categories of skilled profession- One of theals basicmost hypothesesaffected by ofglobalization. this study is Over that differentthe past decade,migration patterns affectthere the has risk emerged profile ofa substantialminers and bodyrural ofpartners. research Mozambican that tracks miners returnpatterns home ofonly international once a year migrationfor annual of leave. health Swazi personnel, miners, in Hcontrast, visit home at least once a month or every month or two. Yet, as assesses causes and consequences, and debates policy responses at global farand as national these studies scales. could Within ascertain, this literature, both engage the case in equally of South risky Africa behav is- iourattracting while theygrowing are awayinterest. at work.For almost Frequency 15 years of return South home Africa therefore has been doesthe target not appear of a ‘global to have raiding’ any mitigating of skilled influence professionals on the by sexualseveral practices devel- ofoped mineworkers countries. atHow work. to dealWhat with it clearly the consequences does do is to of place the Swaziresultant women out- atflow greater of health risk thanprofessionals their Mozambican is a core policy counterparts. issue for the national government.The comparison between Mozambican and Swazi women suggests thatThis the paperMozambican aims to partners to examine may policy be more debates prone and to formingissues concerning other rela- tionshipsthe migration outside of skilledtheir primary health relationshipprofessionals for from a host the of country different and reasons to includingfurnish new emotional insights andon thefinancial recruitment support. patterns One study of skilled has shown health that per- manysonnel. Mozambican The objectives migrants of the form paper longer-term are twofold: attachments at the place of work,• To even provide to the an point audit of of establishing the organization second and households patterns withof recruit- South African mentwomen. of 56skilled In some professionals cases, increased from South poverty Africa from in a reducedthe health flow of remittancessector. (becauseThe paper of draws the demands upon a detailedof a second analysis household of recruitment in South Africa) mayadvertising force rural appearing women in to the seek South support African through Medical other Journal relation for- ships. However,the period most 2000-2004 Mozambican and amigrants series of are interviews forced to conducted defer 60% with of their payprivate to Mozambique, recruiting enterprises.a policy that enjoys almost universal support amongst• Based the partners upon the of abovemigrants. analysis57 and additional interviews with A finalkey common stakeholders feature in thatthe South emerged African in this health study sector,between the paper Mozambiqueoffers anda series Swaziland, of recommendations by both men and for addressingwomen, is the lowproblem level of of personalskilled knowledge health migration.of HIV status. These This recommendations is clearly a conscious are grounded choice since testingin both is available South African and accessible experience to all. and The an interrogationreasons for the of reluc inter-- tance tonational be tested debates require and further ‘good investigation. policy’ practice However, for regulating it is doubtful recruit- that evenment. if the rates of knowledge of status were increased it would lead to higherThe paper rates is of organized disclosure. into Clearly, five sections. considerable Section stigma Two still positions surrounds thedebates disease. about Miners the migration and partners of skilled are largely health uninterested professionals in withinknowing a their statuswider andliterature in disclosing that discusses it to others, the international especially to mobilitytheir own of partners talent. and families.Section Three reviews research on the global circulation of health professionals,This study focusing has confirmed in particular that upon mobility debates and relatingvulnerability to the are experience intimate- lyof connected.countries in It the has developing also suggested world. that Section the causes Four and moves consequences the focus from of vulnerabilityinternational of to migrants South African and their issues partners and provides are closely new connected. empirical Themate- primaryrial drawn objective from the was survey not to of reconfirm recruitment much patterns of what and we key already interviews know aboutundertaken the vulnerability with health of sector migrant recruiters miners operatingat work but in toSouth examine Africa. the perceptionsSection Five and addresses attitudes the of questions the rural ofpartners changing of miners policy and,interventions thereby, in toSouth shed Africa more lighttowards than the currently outflow exists of skilled on the health vulnerability professionals profile and of the womenrecruitment in migrant-sending of foreign health areas. professionals to work in South Africa. The

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EXECUTIVE SUMMARY Endnotes ealth workers are one of the categories of skilled profession- 1 C. Evian, M. Fox, W. MacLeod, S. Slotow and S. Rosen, “Prevalence of HIV als most affected by globalization. Over the past decade, in Workforces in Southern Africa, 2000-2001” South African Medical Journal there has emerged a substantial body of research that tracks 94 (2004): 125-30. patterns of international migration of health personnel, 2 K. Jochelson, M. Mothibeli and J. Leger, “Human Immunodeficiency Virus H and Migrant Labor in South Africa” International Journal of Health Services 21 assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is (1991): 157-73. attracting growing interest. For almost 15 years South Africa has been 3 E. Gouws and Q. Abdool Karim, “HIV Infection in South Africa: The the target of a ‘global raiding’ of skilled professionals by several devel- Evolving Epidemic” In S. Abdool Karim and Q. Abdool Karim, Eds, HIV/ oped countries. How to deal with the consequences of the resultant out- AIDS in South Africa (Cambridge: Cambridge University Press, 2005), p. 60. flow of health professionals is a core policy issue for the national gov- 4 J. Glynn, J. Murray, A. Bester, G. Nelson, S. Shearer and P. Sonnenberg, ernment. “Effects of Duration of HIV Infection and Secondary Tuberculosis This paper aims to to examine policy debates and issues concerning Transmission on Tuberculosis Incidence in the South African Gold Mines” the migration of skilled health professionals from the country and to AIDS 22 (2008): 1859-67; S. Basu, D. Stuckler, G. Gonsalves and M. Lurie, furnish new insights on the recruitment patterns of skilled health per- “The Production of Consumption: Addressing the Impact of Mineral Mining sonnel. The objectives of the paper are twofold: on Tuberculosis in Southern Africa” Globalization and Health 5:11 (2009). • To provide an audit of the organization and patterns of recruit- 5 J. Hargrove, “Migration, Mines and Mores: The HIV Epidemic in Southern ment of skilled professionals from South Africa in the health Africa” South African Journal of Science 104(1&2) (2008): 53-61. sector. The paper draws upon a detailed analysis of recruitment 6 C. Campbell, Letting Them Die: Why HIV/AIDS Prevention Programmes Often advertising appearing in the South African Medical Journal for Fail (London: James Currey, 2003); C. Campbell, “Migrancy, Masculine the period 2000-2004 and a series of interviews conducted with Identities and AIDS: The Psychosocial Context of HIV Transmission on the private recruiting enterprises. South African Gold Mines” In E. Kalipeni, S. Craddock, J. Oppong and J. • Based upon the above analysis and additional interviews with Ghosh, eds. HIV & AIDS in Africa: Beyond Epidemiology (Oxford: Blackwell, key stakeholders in the South African health sector, the paper 2004), pp. 144-54; B. Williams, D. Taljaard, C. M. Campbell, E. Gouws, offers a series of recommendations for addressing the problem of L. Ndhlovu, J. Van Dam, M. Carael and B. Auvert, “Changing Patterns of skilled health migration. These recommendations are grounded Knowledge, Reported Behaviour and Sexually Transmitted Infections in a in both South African experience and an interrogation of inter- South African Gold Mining Community” AIDS 17 (2003): 2099-2117. national debates and ‘good policy’ practice for regulating recruit- 7 R. Packard, White Plague, Black Labor: Tuberculosis and the Political Economy ment. of Health and Disease in South Africa (Berkeley: UC Press, 1989); E. Katz, The paper is organized into five sections. Section Two positions The White Death: Silicosis on the Witwatersrand Gold Mines, 1886-1910 debates about the migration of skilled health professionals within a (Johannesburg: Witwatersrand University Press, 1994); K. Jochelson, The wider literature that discusses the international mobility of talent. Colour of Disease: Syphilis and Racism in South Africa, 1880-1950 (Oxford: Section Three reviews research on the global circulation of health pro- Palgrave, 2001); S. Marks, “The Silent Scourge? Silicosis, Respiratory Disease fessionals, focusing in particular upon debates relating to the experience and Gold Mining in South Africa” Journal of Ethnic and Migration Studies 32 of countries in the developing world. Section Four moves the focus from (4) (2006): 569-89. international to South African issues and provides new empirical mate- 8 S. Marks, “An Epidemic Waiting to Happen? The Spread of HIV/AIDS in rial drawn from the survey of recruitment patterns and key interviews South Africa in Social and Historical Perspective” African Studies 61 (2002): undertaken with health sector recruiters operating in South Africa. 13-26. Section Five addresses the questions of changing policy interventions in 9 A. Dladla, C. Hiner, E. Qwana and M. Lurie, “Speaking to Rural Women: South Africa towards the outflow of skilled health professionals and the The Sexual Partnerships of Rural South African Women whose Partners are recruitment of foreign health professionals to work in South Africa. The Migrants” Society inTransition 32(1) (2001). 10 C. Collins, “Mozambique’s HIV/AIDS Pandemic: Grappling with Apartheid’s

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EXECUTIVELegacy” UNRISDSUMMARY Programme on Social Policy and Development, Paper No. 24, 2006, p. 5. 11 K. Macarow, “Transmissionealth workers Routes: are one The of Global the categories AIDS Epidemic of skilled in profession- South Africa and France”als Globalmost affected South 2(2) by globalization.(2008): 92-111. Over the past decade, 12 M. Lurie, B. Williams,there K.has Zuma, emerged D. Mkaya-Mwamburi,a substantial body of G. research Garnett, that M. Sweat,tracks J. Gittelsohn andpatterns S. Abdool of internationalKarim, “Who migrationInfects Whom? of health HIV-1 personnel, Concordance and DiscordanceH Among Migrant and Non-Migrant Couples in South Africa” assesses causes and consequences, and debates policy responses at global AIDSand 17(15) national (2003): scales. 2245-52; Within M. this Lurie, literature, B. Williams, the case K. Zuma,of South D. AfricaMkaya- is Mwamburi,attracting G. Garnett, growing A.interest. W. Sturm, For almost M. Sweat, 15 years J. Gittelsohn South Africa and S. has Abdool been Karim,the “The target Impact of a ‘globalof Migration raiding’ on of HIV-1 skilled Transmission: professionals Aby Study several of devel-Migrant and Non-Migrantoped countries. Men, How and to Their deal withPartners” the consequences Sexually Transmitted of the resultantDiseases 40 out- (2003):flow 149-56; of health K. Zuma,professionals M. Lurie, is a B. core Williams, policy D.issue Mkaya-Mwamburi, for the national gov-G. Garnett,ernment. A. Sturm, “Risk Factors of Sexually-Transmitted Infections among Migrant Thisand Non-Migrant paper aims to Sexual to examine Partnerships policy debatesfrom Rural and Southissues Africa”concerning Epidemiologythe migration and Infection of skilled 133 health(2005): professionals 421-8. from the country and to 13 B. Auvertfurnish et al,new “HIV insights Infection on the Among recruitment Youth patternsin a South of skilledAfrican health Mining per- Townsonnel. is Associated The objectives with Herpes of the Simplex paper Virus-2are twofold: Seropositivity and Sexual Behaviour”• AIDS To provide 15 (2001): an audit 885-98; of the R. organizationGray et al, “Probability and patterns of ofHIV-1 recruit- Transmission mentPer Coital of skilled Act inprofessionals Monogamous, from Heterosexual, South Africa HIV-1 in the Discordanthealth Couples in Rakai,sector. Uganda” The paper The draws Lancet upon 357 a(2001): detailed 1149-53; analysis S-G of recruitment Mahiane et al, “Transmissionadvertising Probabilities appearing of HIV in theand South Herpes African Simplex Medical Virus Type Journal 2, Effect for of Male Circumcisionthe period and 2000-2004 Interaction: and A a Longitudinalseries of interviews Study conductedin a Township with of South Africa”private AIDS 23recruiting (2009): enterprises. 377-83; M-C Boily et al, “Heterosexual Risk of HIV-1• Infection Based Perupon Sexual the above Act: Aanalysis Systematic and additionalReview and interviews Meta-Analysis with of Observationalkey stakeholdersStudies” The inLancet the South9(2) (2009):118-129; African health sector,W. Miller, the N.paper Rosenberg, S.offers Rutstein a series and of K. recommendations Powers, “Role of Acutefor addressing and Early the HIV problem Infection of in the Sexualskilled Transmission health migration.of HIV” Current These Opinion recommendations in HIV & AIDS are grounded 5(4) (2010): 277-82.in both South African experience and an interrogation of inter- 14 M. Coffee, M.national Lurie and debates G. Garnett, and ‘good “Modelling policy’ practice the Impact for regulatingof Migration recruit- on the HIV Epidemicment. in South Africa” AIDS 21(3) (2007): 343-50. 15 J. Crush,The S. Peberdy paper is and organized V. Williams, into five“International sections. Section Migration Two and positions the Southerndebates African about Region” the migration Report forof skilledGlobal health Commission professionals on International within a Migrationwider (GCIM), literature Geneva, that discusses 2004. the international mobility of talent. 16 J. Crush,Section The StruggleThree reviews for Swazi research Labour, on 1890-1920 the global (Montreal circulation and of Kingston:health pro- McGillfessionals, Queens Press,focusing 1989); in particular P. Harries, upon Work, debates Culture, relating and Identity: to the experienceMigrant Laborersof countries in Mozambique in the and developing South Africa, world. c. Section1860-1910 Four (Portsmouth moves the focusNH: from Heinemann,international 1994). to South African issues and provides new empirical mate- 17 F. de Vletter,rial drawn Sons from of Mozambique: the survey of Mozambican recruitment Miners patterns and and Post-Apartheid key interviews South Africaundertaken, SAMP Migration with health Policy sector Series recruiters No. 8, Cape operating Town, in 1998. South Africa. 18 SwazilandSection Vulnerability Five addresses Assessment the questions Committee of changing (VAC), policy “A Study interventions to in DetermineSouth the Africa Links towards between the HIV/AIDS, outflow of skilledCurrent health Demographic professionals Status and and the Livelihoodsrecruitment in Rural of foreignSwaziland” health (Mbabane, professionals 2004). to work in South Africa. The 19 Ministry of Health and Social Welfare, Swaziland, 9th Round of National HIV

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EXECUTIVE SUMMARY Sero-surveillance in women attending antenatal care services at health facili- ties in Swaziland. Survey report, 2005. ealth workers are one of the categories of skilled profession- 20 A. Whiteside, C. Andrade, L. Arrehag, S. Dlamini, T. Ginindza and A. als most affected by globalization. Over the past decade, Parikh, “The Socio-Economic Impact of HIV/AIDS in Swaziland” Report for there has emerged a substantial body of research that tracks HEARD, Durban, 2006. patterns of international migration of health personnel, 21 A. Whiteside, “What Is Driving the HIV/AIDS Epidemic in Swaziland and H What More Can We Do About It?” Report for NERCHA and UNAIDS, assesses causes and consequences, and debates policy responses at global and national scales. Within this literature, the case of South Africa is Mbabane, 2003, p.32. attracting growing interest. For almost 15 years South Africa has been 22 Ibid. the target of a ‘global raiding’ of skilled professionals by several devel- 23 Ibid, p. 8. oped countries. How to deal with the consequences of the resultant out- 24 J. Crush, B. Williams, E. Gouws and M. Lurie, “Migration and HIV/AIDS in flow of health professionals is a core policy issue for the national gov- South Africa” Development Southern Africa 22 (2005): 293-318. ernment. 25 Whiteside, “What Is Driving the HIV/AIDS Epidemic in Swaziland,” p. 33. This paper aims to to examine policy debates and issues concerning 26 Campbell, Letting Them Die. the migration of skilled health professionals from the country and to 27 Whiteside, “What Is Driving the HIV/AIDS Epidemic in Swaziland,” p. 12. furnish new insights on the recruitment patterns of skilled health per- 28 F. Muwanga, Impact of HIV/AIDS on Agriculture and the Private Sector in sonnel. The objectives of the paper are twofold: Swaziland (Mbabane: TAT Health Services, 2002), p. 26. • To provide an audit of the organization and patterns of recruit- 29 Central Statistical Office, Report on the 1997 Population Census (Mbabane, ment of skilled professionals from South Africa in the health 1998). sector. The paper draws upon a detailed analysis of recruitment 30 Collins, “Mozambique’s HIV/AIDS Pandemic,” p. 2. advertising appearing in the South African Medical Journal for 31 R. Waterhouse, “The Impact of HIV/AIDS on Farmers’ Knowledge of Seed: the period 2000-2004 and a series of interviews conducted with Case study of Chokwe District, Gaza Province, Mozambique” Research Report private recruiting enterprises. of the International Crops Research Institute for the Semi-Arid Tropics, 2004, • Based upon the above analysis and additional interviews with p. 7. key stakeholders in the South African health sector, the paper 32 C. Arndt, “HIV/AIDS, Human Capital and Economic Prospects for offers a series of recommendations for addressing the problem of Mozambique” Africa Region Working Paper Series No. 48, World Bank, skilled health migration. These recommendations are grounded Washington, p. 39. in both South African experience and an interrogation of inter- 33 K. Foreit, A. Barreto, P. Noya and I. Nhatavf, “Population Movements and the national debates and ‘good policy’ practice for regulating recruit- Spread of HIV/AIDS in Mozambique” Journal of Health and Human Services ment. Administration 24 (2001): 279-94. The paper is organized into five sections. Section Two positions 34 S. Beckmann and P. Rai, Mozambique: HIV/AIDS, Work and Development debates about the migration of skilled health professionals within a (Geneva: ILO, 2005), p. 4 wider literature that discusses the international mobility of talent. 35 F. de Graca Bukali, “HIV/AIDS Prevention and Care in Mozambique, A Section Three reviews research on the global circulation of health pro- Socio-Cultural Approach” UNESCO, Maputo, 2002, p. 17. fessionals, focusing in particular upon debates relating to the experience 36 Beckman and Rai, Mozambique. of countries in the developing world. Section Four moves the focus from 37 Ibid, p. 12. international to South African issues and provides new empirical mate- 38 R. First, Black Gold: The Mozambican Miner, Proletarian and Peasant (London: rial drawn from the survey of recruitment patterns and key interviews Palgrave Macmillan, 1983). undertaken with health sector recruiters operating in South Africa. 39 de Vletter, Sons of Mozambique. Section Five addresses the questions of changing policy interventions in 40 F. de Vletter, “Labour Migration to South Africa: The Lifeblood for Southern South Africa towards the outflow of skilled health professionals and the Mozambique”, in On Borders: Perspectives on International Migration in Southern recruitment of foreign health professionals to work in South Africa. The Africa, D McDonald, Ed, (Cape Town and New York: SAMP and St Martin’s Press, 2000), pp. 46-70.

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41EXECUTIVE Waterhouse,SUMMARY “The Impact of HIV/AIDS on Farmers’ Knowledge of Seed,” p. 12. 42 H. Simelane and ealthJ. Crush, workers Swaziland are one Moves: of the Perceptions categories and of skilledPatterns profession- of Modern Migration, SAMPals Migration most affected Policy by Series globalization. No 32, Cape Over Town, the past2004. decade, 43 Emalangeni, equivalentthere has to emergedZAR. a substantial body of research that tracks 44 F. de Vletter, Migrationpatterns and of Development international in migrationMozambique: of health Poverty, personnel, Inequality and SurvivalH, SAMP Migration Policy Series No 43, Cape Town, 2006. assesses causes and consequences, and debates policy responses at global 45 Whiteside,and national “What scales.Is Driving Within the HIV/AIDSthis literature, Epidemic the case in ofSwaziland,” South Africa p. 22. is 46 Campbell,attracting Letting growing Them Dieinterest.. For almost 15 years South Africa has been 47 B. Tobias,the target “A Descriptive of a ‘global Study raiding’ of the of skilledCultutal professionals Mores and Beliefsby several Towards devel- HIV/AIDSoped countries. in Swaziland, How Southern to deal with Africa” the Internationalconsequences Journal of the for resultant the out- Advancementflow of healthof Counselling professionals 23 (2001): is a core 99-113; policy A. issue Buseh, for L.the Glass national and B.gov- McElmurry,ernment. “Cultural and Gender Issues Related to HIV/AIDS Prevention in Rural ThisSwaziland” paper aimsHealth to Careto examine for Women policy International debates and 23 issues(2002): concerning 173-84; UNDP,the “Gender migration Focused of skilled Responses health toprofessionals HIV/AIDS. from The theNeeds country of Women and to Infectedfurnish With new and insights Affected on by the HIV/AIDS,” recruitment Mbabane, patterns of2002; skilled H. Simelane,health per- “Husbands,sonnel. Wives The objectives and Domestic of the Violence paper are in twofold:Post-Colonial Swaziland” unpublished• report, To provide University an audit of ofSwaziland, the organization 2006. and patterns of recruit- 48 UNDP, “Genderment Focused of skilled Responses,” professionals p. 1. from South Africa in the health 49 Government sector.of Swaziland, The paper “Policy draws Document upon a detailed on HIV/AIDS analysis and of recruitmentSTD Prevention andadvertising Control” appearing Mbabane, in 1998; the SouthGovernment African of Medical Swaziland, Journal for “Swaziland Nationalthe period Strategic 2000-2004 Plan andfor HIV/AIDS a series of interviews2000-2005,” conducted Mbabane, with 2000. private recruiting enterprises. 50 S. Gumedze,• BasedHIV/AIDS upon and the Human above analysisRights in and Swaziland additional (Pretoria: interviews Centre with for the Study of AIDS,key stakeholders 2004), p. 24.in the South African health sector, the paper 51 P. McKenzie, offers“Chokwe: a series Dying of recommendations on its Feet”, Ottawa for Citizenaddressing,Thursday, the problem August of 10, 2006. skilled health migration. These recommendations are grounded 52 Campbell, Mzaidumein both South and Williams, African “Genderexperience as andan Obstacle an interrogation to Condom of inter- Use”; C. MacPhail,national and debates C. Campbell, and ‘good “I Thinkpolicy’ Condomspractice for are regulating Good But, recruit- Aai, I Hate Those Things:ment. Condom Use Among Adolescents and Young People in a SouthernThe African paper Township” is organized Social into Science five sections. and Medicine Section 52 Two(2001): positions 1613-27. 53 Campbell,debates Letting about Them the migrationDie, p. 156. of skilled health professionals within a 54 Collins,wider “Mozambique’s literature that HIV/AIDS discusses thePandemic,” international p. 1. mobility of talent. 55 Campbell,Section Letting Three Them reviews Die. research on the global circulation of health pro- 56 S. Lubkemann,fessionals, “Migratoryfocusing in Copingparticular in Wartimeupon debates Mozambique: relating toAn the Anthropology experience of Violenceof countries and Displacement in the developing in ‘Fragmented world. Section Wars’” Four Journal moves of Peacethe focus Research from 42 (4)international (2005): 493-508. to South African issues and provides new empirical mate- 57 de Vletter,rial drawn Sons offrom Mozambique 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 Migration Policy Series ealth workers are one of the categories of skilled profession- 1. Covert Operations: Clandestine Migration, Temporary Work and Immigration als most affected by globalization. Over the past decade, Policy in South Africa (1997) ISBN 1-874864-51-9 there has emerged a substantial body of research that tracks 2. Riding the Tiger: Lesotho Miners and Permanent Residence in South Africa Hpatterns of international migration of health personnel, (1997) ISBN 1-874864-52-7 assesses causes and consequences, and debates policy responses at global 3. International Migration, Immigrant Entrepreneurs and South Africa’s Small and national scales. Within this literature, the case of South Africa is Enterprise Economy (1997) ISBN 1-874864-62-4 attracting growing interest. For almost 15 years South Africa has been 4. Silenced by Nation Building: African Immigrants and Language Policy in the the target of a ‘global raiding’ of skilled professionals by several devel- New South Africa (1998) ISBN 1-874864-64-0 oped countries. How to deal with the consequences of the resultant outflow of health professionals is a core policy issue for the national gov- 5. Left Out in the Cold? Housing and Immigration in the New South Africa ernment. (1998) ISBN 1-874864-68-3 This paper aims to to examine policy debates and issues concerning 6. Trading Places: Cross-Border Traders and the South African Informal Sector the migration of skilled health professionals from the country and to (1998) ISBN 1-874864-71-3 furnish new insights on the recruitment patterns of skilled health per- 7. Challenging Xenophobia: Myth and Realities about Cross-Border Migration in sonnel. The objectives of the paper are twofold: Southern Africa (1998) ISBN 1-874864-70-5 • To provide an audit of the organization and patterns of recruit- 8. Sons of Mozambique: Mozambican Miners and Post-Apartheid South Africa ment of skilled professionals from South Africa in the health (1998) ISBN 1-874864-78-0 sector. The paper draws upon a detailed analysis of recruitment advertising appearing in the South African Medical Journal for 9. Women on the Move: Gender and Cross-Border Migration to South Africa the period 2000-2004 and a series of interviews conducted with (1998) ISBN 1-874864-82-9. private recruiting enterprises. 10. Namibians on South Africa: Attitudes Towards Cross-Border Migration and • Based upon the above analysis and additional interviews with Immigration Policy (1998) ISBN 1-874864-84-5. key stakeholders in the South African health sector, the paper 11. Building Skills: Cross-Border Migrants and the South African Construction offers a series of recommendations for addressing the problem of Industry (1999) ISBN 1-874864-84-5 skilled health migration. These recommendations are grounded 12. Immigration & Education: International Students at South African in both South African experience and an interrogation of inter- Universities and Technikons (1999) ISBN 1-874864-89-6 national debates and ‘good policy’ practice for regulating recruit- 13. The Lives and Times of African Immigrants in Post-Apartheid South Africa ment. (1999) ISBN 1-874864-91-8 The paper is organized into five sections. Section Two positions debates about the migration of skilled health professionals within a 14. Still Waiting for the Barbarians: South African Attitudes to Immigrants and wider literature that discusses the international mobility of talent. Immigration (1999) ISBN 1-874864-91-8 Section Three reviews research on the global circulation of health pro- 15. Undermining Labour: Migrancy and Sub-contracting in the South African fessionals, focusing in particular upon debates relating to the experience Gold Mining Industry (1999) ISBN 1-874864-91-8 of countries in the developing world. Section Four moves the focus from 16. Borderline Farming: Foreign Migrants in South African Commercial international to South African issues and provides new empirical mate- Agriculture (2000) ISBN 1-874864-97-7 rial drawn from the survey of recruitment patterns and key interviews 17. Writing Xenophobia: Immigration and the Press in Post-Apartheid South undertaken with health sector recruiters operating in South Africa. Africa (2000) ISBN 1-919798-01-3 Section Five addresses the questions of changing policy interventions in 18. Losing Our Minds: Skills Migration and the South African Brain Drain (2000) South Africa towards the outflow of skilled health professionals and the ISBN 1-919798-03-x recruitment of foreign health professionals to work in South Africa. The 19. Botswana: Migration Perspectives and Prospects (2000) ISBN 1-919798-04-8

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20.EXECUTIVE The Brain SGain:UMMARY Skilled Migrants and Immigration Policy in Post-Apartheid South Africa (2000) ISBN 1-919798-14-5 21. Cross-Border Raidingealth andworkers Community are one Conflictof the categories in the Lesotho-South of skilled profession- African Border Zone (2001)als mostISBN affected 1-919798-16-1 by globalization. Over the past decade, 22. Immigration, Xenophobiathere has andemerged Human a substantial Rights in Southbody ofAfrica research (2001) that tracks ISBNH 1-919798-30-7patterns of international migration of health personnel, assesses causes and consequences, and debates policy responses at global 23. Gender and the Brain Drain from South Africa (2001) ISBN 1-919798-35-8 and national scales. Within this literature, the case of South Africa is 24. Spacesattracting of Vulnerability: growing Migrationinterest. For and almost HIV/AIDS 15 years in South AfricaAfrica (2002)has been ISBNthe 1-919798-38-2 target of a ‘global raiding’ of skilled professionals by several devel- 25. Zimbabweansoped countries. Who Move: How Perspectivesto deal with onthe International consequences Migration of the resultant in out- Zimbabweflow of(2002) health ISBN professionals 1-919798-40-4 is a core policy issue for the national gov- 26. The Borderernment. Within: The Future of the Lesotho-South African International BoundaryThis (2002) paper ISBN aims 1-919798-41-2 to to examine policy debates and issues concerning 27. Mobilethe Namibia: migration Migration of skilled Trends health and professionals Attitudes (2002)from the ISBN country 1-919798-44-7 and to furnish new insights on the recruitment patterns of skilled health per- 28. Changing Attitudes to Immigration and Refugee Policy in Botswana (2003) sonnel. The objectives of the paper are twofold: ISBN 1-919798-47-1 • To provide an audit of the organization and patterns of recruit- 29. The New Brainment Drain of skilled from Zimbabwe professionals (2003) from ISBN South 1-919798-48-X Africa in the health 30. Regionalizingsector. Xenophobia? The paper Citizen draws Attitudes upon a detailedto Immigration analysis and of recruitmentRefugee Policy in Southernadvertising Africa appearing (2004) ISBN in the 1-919798-53-6 South African Medical Journal for 31. Migration, Sexualitythe period and 2000-2004 HIV/AIDS and in Rurala series South of interviews Africa (2004) conducted with ISBN 1-919798-63-3private recruiting enterprises. 32. Swaziland• Moves: Based Perceptions upon the above and Patterns analysis ofand Modern additional Migration interviews (2004) with ISBN 1-919798-67-6key stakeholders in the South African health sector, the paper offers a series of recommendations for addressing the problem of 33. HIV/AIDS andskilled Children’s health Migrationmigration. in These Southern recommendations Africa (2004) are grounded ISBN 1-919798-70-6in both South African experience and an interrogation of inter- 34. Medical Leave:national The Exodus debates of and Health ‘good Professionals policy’ practice from for Zimbabwe regulating (2005) recruit- ISBN 1-919798-74-9ment. 35. Degrees Theof Uncertainty: paper is organized Students into and five the sections. Brain Drain Section in Southern Two positions Africa (2005)debates ISBN about1-919798-84-6 the migration of skilled health professionals within a 36. Restlesswider Minds: literature South that African discusses Students the international and the Brain mobility Drain (2005) of talent. ISBNSection 1-919798-82-X Three reviews research on the global circulation of health professionals, focusing in particular upon debates relating to the experience 37. Understanding Press Coverage of Cross-Border Migration in Southern Africa of countries in the developing world. Section Four moves the focus from since 2000 (2005) ISBN 1-919798-91-9 international to South African issues and provides new empirical mate- 38. Northernrial drawn Gateway: from Cross-Border the survey of Migration recruitment Between patterns Namibia and key and interviews Angola (2005)undertaken ISBN 1-919798-92-7 with health sector recruiters operating in South Africa. 39. Early SectionDepartures: Five Theaddresses Emigration the questions Potential of of changing Zimbabwean policy Students interventions (2005) in ISBNSouth 1-919798-99-4 Africa towards the outflow of skilled health professionals and the 40. Migrationrecruitment and Domestic of foreign Workers: health Worlds professionals of Work, to workHealth in and South Mobility Africa. in The Johannesburg (2005) ISBN 1-920118-02-0

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EXECUTIVE SUMMARY 41. The Quality of Migration Services Delivery in South Africa (2005) ISBN 1-920118-03-9 ealth workers are one of the categories of skilled profession- 42. States of Vulnerability: The Future Brain Drain of Talent to South Africa als most affected by globalization. Over the past decade, (2006) ISBN 1-920118-07-1 there has emerged a substantial body of research that tracks 43. Migration and Development in Mozambique: Poverty, Inequality and Survival Hpatterns of international migration of health personnel, (2006) ISBN 1-920118-10-1 assesses causes and consequences, and debates policy responses at global 44. Migration, Remittances and Development in Southern Africa (2006) and national scales. Within this literature, the case of South Africa is ISBN 1-920118-15-2 attracting growing interest. For almost 15 years South Africa has been the target of a ‘global raiding’ of skilled professionals by several devel- 45. Medical Recruiting: The Case of South African Health Care Professionals oped countries. How to deal with the consequences of the resultant out- (2007) ISBN 1-920118-47-0 flow of health professionals is a core policy issue for the national gov- 46. Voices From the Margins: Migrant Women’s Experiences in Southern Africa (2007) ernment. ISBN 1-920118-50-0 This paper aims to to examine policy debates and issues concerning 47. The Haemorrhage of Health Professionals From South Africa: Medical Opinions the migration of skilled health professionals from the country and to (2007) ISBN 978-1-920118-63-1 furnish new insights on the recruitment patterns of skilled health per- 48. The Quality of Immigration and Citizenship Services in Namibia (2008) sonnel. The objectives of the paper are twofold: ISBN 978-1-920118-67-9 • To provide an audit of the organization and patterns of recruitment of skilled professionals from South Africa in the health 49. Gender, Migration and Remittances in Southern Africa (2008) sector. The paper draws upon a detailed analysis of recruitment ISBN 978-1-920118-70-9 advertising appearing in the South African Medical Journal for 50. The Perfect Storm: The Realities of Xenophobia in Contemporary South Africa the period 2000-2004 and a series of interviews conducted with (2008) ISBN 978-1-920118-71-6 private recruiting enterprises. 51. Migrant Remittances and Household Survival in Zimbabwe (2009) • Based upon the above analysis and additional interviews with ISBN 978-1-920118-92-1 2009 key stakeholders in the South African health sector, the paper 52. Migration, Remittances and ‘Development’ in Lesotho (2010) offers a series of recommendations for addressing the problem of ISBN 978-1-920409-26-5 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

1 36 kkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk Co-Published by:

southern AfriCAn MigrAtion ProgrAMMe Idasa and the University of Cape Town Cape Town, South Africa and Southern African Research Centre Kingston, Ontario, Canada

internAtionAl orgAnizAtion for MigrAtion Regional Office for Southern Africa Pretoria, South Africa