Could the Step-Up deepen healthcare worker brain drain in the Pacific?

Nurses on a maternity ward, Fiji (Credit: DFAT/Flickr CC BY 2.0)

In the era of the Pacific Step-Up, Australian aid for health has taken a publicity backseat to the flagship policies of increased labour mobility and regional educational opportunities. The Health for Development Strategy 2015-2020, describes Australia’s approach to improving health through aid, wherein health system strengthening is described as its highest priority, of which human resources is an essential building block. However, an inconsistency threatens to hamper efforts towards health system strengthening in Pacific island nations – the role Australia plays in hiring health care professionals from the very nations we are seeking to assist.

Two key pillars of the Step-Up – increased regional education opportunities and labour mobility – may well prove to be avenues that contribute to the problem of ‘brain drain’ and deepen the human resource deficits that weaken healthcare systems in aid recipient nations. A critique of the issues that arise with recruitment of health workers from our Pacific neighbours is timely, and required, to ensure that our efforts to address Australian workforce shortages do not thwart capacity-building endeavours in the Pacific’s struggling healthcare systems.

Research shows that migration by Pacific island health professionals to Australia is high, and that it worsens the shortage of health workers in source countries. Joel Negin’s paper on Australia and New Zealand’s contribution to Pacific Island health worker brain drain reported that during the 2006 Census, 455 Pacific born doctors and 1158 Pacific born nurses and midwives were working in Australia. By the 2016 Census these numbers had ballooned to 607 doctors and 2954 nurses. In some cases the number of migrant healthcare workers in Australia from certain nations outnumber the local workforce in their home countries. Stemming from this migration, developing nations not only lose those best equipped to deliver healthcare to their vulnerable populations, they also lose the financial investment made in the education of those personnel. As a result, countries who can ill afford such losses subsidise healthcare in the west. As Kimberley Oman and others pointed out in 2006, where donors fund in-country specialist training programs, as Australian Aid has done in the Pacific, many graduates migrate to use those skills in the donor country, and Australia inadvertently becomes beneficiary of its own aid.

In response to this unjust dynamic, the World Health Organisation’s Global Code of Practice on the International Recruitment of Health Personnel (the Code) was adopted by all 193 Member States of the World Health Assembly (WHA), including Australia on 21 May 2010. Article 5.1 of the Code discourages active recruitment of health personnel from developing countries facing critical shortages. However, even in the absence of active recruitment, various push and pull factors drive the exodus to wealthier states, such as relatively poor remuneration at home, limited career prospects, difficult working conditions, and inadequate standards of living. Among the pull factors, access to tertiary qualifications and specialist training pathways not available in one’s home country are at the forefront. Sponsored (aid or other) trainees often sent with the intention of up-skilling and returning, often elect to stay in the host training country once they and their family have acclimatised to life abroad. In this way, aid programs such as the Australian Government’s Australia Awards, with its emphasis on bringing regional scholars to Australia for university training, present a means to draw more healthcare workers to Australia for study that may culminate in one-way migration.

Nine working visa classes exist to facilitate migration for skilled healthcare professionals, such as doctors and nurses, to Australia. As part of its Pacific Step-Up the Australian Government’s Pacific Labour Scheme provides for an uncapped number of low- and semi-skilled migrants to come to Australia to work for up to three years. Some nursing carers already qualify for migration under that scheme. It remains to be seen whether the scheme could be expanded to include highly skilled healthcare professionals such as doctors and nurses as well. Relaxed immigration conditions that may lure more migrant healthcare workers away from where their services are most needed risks undermining our health development goals and commitments.

In spite of the apparent injustice of the current system, it is important to adopt a nuanced understanding of the interplay of migration, healthcare and human resources in the Pacific. As John Connell points out, no adequate data exist to produce a costbenefit analysis ‘that elegantly balances education costs, remittances, social costs’ with the presumed harms of the migration of Pacific healthcare professionals. Furthermore, for Pacific Islanders, the descendants of master navigators who populated a vast watery continent, migration needs to be considered in the continuum of millenia-old habits of voyaging. Doyle and Roberts argued that ‘skilled migration is part of a broad cultural tradition of migration within the Pacific Islands, and is an accepted and valued part of Pacific life’. Indeed, there may be pecuniary benefits to source nations, not least income sent home to families via remittances, which make up a significant percentage of the Gross Domestic Product in some Pacific island states. However, it is difficult to compare the gains made through remittances to the loss incurred through brain drain.

Gillian Brock in her book, Debating Brain Drain, mooted some punitive measures as deterrents to migration, such as obligations to continue to pay tax to one’s home nation, or complete a period of compulsory national service. However such strategies place the burden on individuals seeking to better their circumstances, rather than the systems that give rise to such disparities and yearnings, and sit in tension with Article 13 of the UN Declaration of Human Rights which enshrines an individual’s right to freedom of movement, and right to leave any country, including their own, should they choose. Instead, to rectify the imbalance of power and the net loss sustained by source countries to create a more just system overall, the Code advocates that ‘both source and destination countries should derive benefits from the international migration of health personnel’. It then offers suggestions to address the losses created by such recruitment, such as host countries offering compensation to the source nations, or providing enhanced in-country training opportunities or material aid in the form of medical technology commensurate with the value of the personnel lost, although the calculation of such loss is self-evidently impractical.

Like many nations, Australia has yet to explicitly address methods to decrease dependence on foreign healthcare workers, and provide remedial measures which acknowledge that Australia benefits from migrant personnel at the expense of source countries. To balance the scales, Australia needs to critically examine the intersection of healthcare recruitment practices, development aid, and immigration policies to ensure:

  • no active targeting to hire healthcare workers from our aid recipient nations;
  • push factors which encourage migration of healthcare workers are addressed through the development aid program;
  • after aid-supported education is complete in Australia, healthcare workers are encouraged to return to their home countries with adequate incentives;
  • measures to enhance labour mobility do not extend to facilitating increased skilled healthcare worker migration.

In this way, as Australia ‘steps up’ its support for its Pacific neighbours, we can be confident that our efforts are considerate, consistent and just.

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Matthew Bray

Dr Matt Bray is a Rotuman-Australian medical doctor who has worked as a clinician and researcher in Fiji. He is currently completing a Master of Public Health through James Cook University.


  • Most senior health workers in Pacific Island Countries and Territories (PICTs) are aware of the brain-drain, push-pull factors, cost benefits, etc. The general opinion amongst senior health workers is that PICTs should produce more health workers. For example, compared to 2012 there is an increased number of medical graduates across the region because of an increased number of medical schools (FNU, UPSM [Fiji], NUS [Samoa] and UPNG [PNG]) and an increased number of international graduates (Cuba, Taiwan, China, etc) apart from the traditional providers (Aust, NZ).

    One of the Pacific Reset options is to strengthen the academic institutions in the PICTs to produce more quality postgraduate training in all health fields.

    PICTs have moved on from the term brain-drain to brain-rotation whereby health workers from the PICTs are working in other PICTs to address their shortage of health workers.

    We welcome the academic debate but we don’t need more studies to tell us our problems. We need solutions.

    * a Pacific Health Worker in the PICTs for 25 years and still learning

  • Dear Dr Matthew

    Your paper does shine an important light in an area that affects healthcare in the Pacific island countries. However I believe that over the last decade strides have been made that might mute your discussion points, especially in regards to the Fiji Islands.

    Your paper quotes Pacific born Doctor numbers working in Australia over a 10 year period showed an increment by 34% in 2016 ( 455 -> 607). In the Fiji Islands, Doctors working in the country increased by 104% (400->815) over the last 5 years (Waqainabete, 2019).

    Moreover, Fiji as a country has developed, and in 2016 a massive increment in Healthcare professionals’ salaries led to more retention of physicians. Additionally bonding and service contracts were strengthened for people sent for specialty training. These two changes are interlinked and seems controversial but is aimed to provide a more sustainable platform for the Fijian healthcare sector to train their own specialists in the future.

    However, solution one that you present seems quite conservative for aid giving nations at most. It is discriminatory. Why should the Fijian people or any others be penalised and not be hired if they were trained overseas? They may have already served their purpose. Soft evidence suggests that within the next few years, the medical field will be saturated in the small Fijian economy and therefore HCP’s will most likely be groomed for export.

    Specific assessments and up to date data need to be collated in order to enhance meaningful change instead of generalising in the pacific. It may therefore be prudent to encourage developing island nations to better address and strengthen their retention tactics instead of using a totalitarian approach.

    • Bula Abdul and thanks for further insights on the great strides made in Fiji for sustainable medical workforce.

      I too am heartened that the salary rises and the foundation of UPSM in Lautoka have led to increases in local medical practitioners and their retention to serve their compatriots.

      For clarification, I was not advocating for the punitive measures so much as listing them in what was a fairly broad discussion of what has been written in largely medical and public health literature about brain drain. The links below in Ryan Edwards response provide a great nuanced discussion from the economics literature and I’m grateful that they highlight the limitations of my own brief writing above.

      Fundamentally, the point of my article was to encourage reflection on Australia’s – and particular the Aid program’s – contribution to brain drain in the Pacific.
      I’ve fallen into using some popular tropes to make the point but thankfully responses like yours and Ryan’s highlight that the agency of “recipient” nations is seeing benefits on both sides of the ledger, and in time Fiji will be a net medical expert exporter, which will benefit neighbours in the region and Fiji itself.
      Thanks for some great sharing!

  • Matthew, thanks for this thoughtful post on some important issues I am very glad are being discussed more. Three comments.

    First, I agree with Connell’s point that we lack the evidence we need for a complete cost-benefit-type analysis, and your point that harms are often presumed.

    Second, although there is not much evidence on the current scheme, a lot of high-quality work has been done (some of which you mention). In particular, the conceptual frameworks in McKenzie and Gibson ( and Docquier and Rapoport ( provide useful starting points for thinking about the channels and what might go on each side of the ledger. Systematic studies credibly estimating these impacts from both the Pacific and other countries indeed give mixed result. However, for the most part, it does not suggest we should presume a drain (see, e.g., these two careful papers on the Filipino experience by Caroline Theoharides , ). Satish Chand made this point most eloquently at the 2019 Pacific Update last Friday, drawing partly from his excellent paper with Michael Clemens on Fiji’s historical experience ( ).

    Finally, on the ballooning numbers you mention, a crude look at the national aggregates from the WDI suggests that nurses per capita in several (read: all that I looked at) Pacific countries are rising. For example, Fiji went from 1.9/1000 in 1999 to 2.9 in 2015 while Kiribati went from 2.3 (1998) to 4.6 (2013). These are of course denominated by population, which grew much slower: 806,000 to 869,000, and 81,000 to 108,000 for the same country-years. I am not sure if the numbers in the Australian and Pacific censuses include those temporarily away, but we should be able to assume these aggregate numbers from the World Bank are broadly consistent with them. My third point is thus that when thinking about sending country human capital stocks the current evidence does not let us rule out that the actual levels remaining and working in the Pacific would not be lower in the absence of exit options, an effect the recent careful studies I’ve linked to above all point towards.

    All this is but to say that (a) I would caution readers against starting from a “drain” prior, as the most careful prior work does not point to this, and (b) we really need more careful, systematic quantitative evidence on the benefits and costs for the diversity of participating countries in 2019. We are working on this at the moment, and welcome more to do the same!

    • Dear Ryan

      Thanks for your feedback and sharing. I really enjoyed your points and the articles shared, going to show that the narrative of presumed harms is a little off the mark and that interestingly, some of the national responses to the “brain drain” have resulted in net gains for the nations on both sides of the ledger.

      I look forward to following your analysis and the quantitative evidence about the impacts of our various labour mobility and skilled migration schemes on our Pacific neighbours.

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