Citation for this: Efendi, F., Ken Mackey, T., Huang, M-C., Chen, C-M. (2016). IJEPA: Gray Area for Health Policy and International Nurse Migration.
Introduction: A global nursing shortage in developed countries has led to active recruitment of nurses, particularly from low- and middle-income countries.1–3 Globally, foreign nurse recruitment is recognized as a quick and simple strategy to meet the growing needs of aging populations and increasingly resource-intensive healthcare services in high-income countries by ensuring acceptable staffing levels in these destination countries.4 Through international recruitment, developed countries do not need to wait for qualified nurses to be trained incountry and instead can leverage investments in healthcare worker education and training in source countries where the costs may be substantially lower.5 Conversely, source countries may struggle to meet their own demands for health personnel and service capacity due to this form of outward migration in a highly skilled and professionalized workforce.5 Hence, liberalization of trade, globalization, and increased international travel have enabled greater access and availability to nurses and other healthcare workers with migration policies also creating strong economic incentives for outward migration.5 This includes “pull” factors from developed countries (e.g. greater demand for healthcare workers, higher wages) and “push” factors in source countries (e.g. low wages, fewer opportunities for professional growth) that have exacerbated the estimated global shortage of 7.2 million healthcare professionals that includes physicians, nurses, caregivers, and other allied healthcare workers.6 This situation is at odds with the World Health Organization7 Global Code of Practice on the International Recruitment of Health Personnel (WHO Code) adopted in 2010, which discourages active recruitment of health staff from countries facing shortages of human resources related to health. Nurse migration is a critical component of the phenomenon of international movement in healthcare workers and has been identified to occur within a country’s borders and across countries with different
healthcare workforce priorities.4 Nurses migrate for a variety of economic, social, professional, personal, and even political reasons.8 Between countries, the number of health personnel, including nurses, leaving low-income countries for developed countries continues to increase significantly.9 Within country, migration of the health workforce commonly occurs in the form of migration from rural to urban areas and
represents a common challenge in low-income and high-income countries alike.5 Ongoing debate on the benefits and detriments of the current flow of transnational nurse migration has been the subject of international attention, a dilemma also more broadly referred to as the global “brain drain” of healthcare workers.2,3
Indonesia is a country that has been significantly impacted by the free movement of nurses globally, particularly through domestic and international policies that have encouraged this mobility.10 This has led to a significant outward flow of Indonesian nurses from 2008 to 2012, with more than 3000 nurses posted to developed country settings.11 These trends may severely compromise access to healthcare services within
Indonesia, especially given its classification by the WHO12 as a country suffering from health worker shortages. Indeed, nursing shortages are part of a broader regional challenge in South-East Asia, an area of the world that is experiencing the greatest shortage of health personnel according to WHO12 with acute shortages in countries including Indonesia, India, and Bangladesh. An important factor that may further impact the outward flow of nursing professionals from Indonesia to other international destinations is the influence of international trade agreements and their treatment of health worker migration. Hence, this article will describe and critically assess the impact of a unique bilateral trade and investment agreement, known as the Indonesia–Japan Economic Partnership Agreement (“IJEPA”), which facilitates a pathway for Indonesian nurses to immigrate to Japan.