Dentistry and Health Sciences at the University of Melbourne â Anna To, for her meticulous analysis of ...... System (IELTS) Band 7 or OET B scores for registration (with âGood Userâ considered the ...... GPA, GAMSAT, IV, personal statement.
HEALTH WORKFORCE MIGRATION TO AUSTRALIA POLICY TRENDS AND OUTCOMES 2004-2010 Lesleyanne Hawthorne Professor: International Health Workforce
2012 Study commissioned and published by Health Workforce Australia
HEALTH WORKFORCE MIGRATION TO AUSTRALIA Policy Trends and Outcomes 2004-2010
Lesleyanne Hawthorne Professor: International Health Workforce Faculty of Medicine, Dentistry and Health Sciences Cleared for Circulation May 30 2012
Scoping Paper Commissioned by Health Workforce Australia
1
Contents Acknowledgements………………………………………………………………………
5
Tables…………………………………………………………………………………….
7
List of Acronyms………………………………………………………………………...
10
Executive Summary……………………………………………………………………..
12
Section 1: Australia’s Skilled Migration Policy Context
40
1.1
Permanent skilled migration to Australia in the Recent Decade………………………...
40
1.2
Temporary skilled migration and Employer/Regional Sponsorship…………………….
47
1.3
Trends in regional Skilled Migration……………………………………………………
52
1.4
The Role of skilled migration compared to Domestic Health workforce training………
53
Section 2: Health Workforce Migration to Australia and Employment Outcomes...
58
2.1
Global demand for migrant health professionals……………………………………….
58
2.2
Health workforce migration to Australia in the recent decade………………………….
59
2.3
Medical practitioners………………………………………………………………….....
66
2.4
Nurses and midwives……………………………………………………………………
71
2.5
Dentists………………………………………………………………………………….
73
2.6
Pharmacists………………………………………………………………………………
75
2.7
Rehabilitation professionals……………………………………………………………..
76
2.8
The role of AHPRA in relation to migrant health professionals……………………
77
Section 3: The Impact of English Testing on Migrant Health Professionals………..
78
3.1
English testing requirements…………………………………………………………....
78
3.2
The impact of English language testing in the 1990s…………………………………
80
3.3
The impact of English language testing 2005-2010………………………………….......
82
3.4
English language testing – 2011 Policy Developments…………………………………..
86
2
Section 4: Access to Vocational Registration – Medicine…………………………….
89
4.1
Pre and post-migration screening……………………………………………………….
89
4.2
Australian Medical Council assessment outcomes – 1978-2005………………………
91
4.3
IMG survey findings 2005-07 (DoHA study)…………………………………………..
94
4.4
AMC assessment outcomes to 2010……………………………………………………
96
4.5
The Competent Authority pathway……………………………………………………...
97
4.6
Additional medical registration pathways……………………………………………...
100
4.7
Specialist registration – overview…………………………………………………….....
101
4.8
Specialist registration – Surgery (case study 1)………………………………………...
103
4.9
Specialist registration – Psychiatry (case study 2)……………………………………...
105
4.10
Conclusion........................................................................................................................
106
Section 5: Access to Vocational Registration – Allied Health………………………..
107
5.1
Nurse migration and assessment………………………………………………………
107
5.2
Dentist migration and assessment……………………………………………………..
109
5.3
Pharmacist migration and assessment…………………………………………………
111
5.4
Physiotherapist migration and assessment……………………………………………..
112
5.5
The case for bridging courses…………………………………………………………..
114
5.6
Conclusion…………………………………………………………………………….....
115
Section 6: Translation to Practice? Selected Country Profiles……………………....
116
6.1
Introduction……………………………………………………………………………....
116
6.2
New Zealand……………………………………………………………………………..
117
6.3
United Kingdom/ Ireland………………………………………………………………...
118
6.4
South Africa……………………………………………………………………………...
119
6.5
India……………………………………………………………………………………...
121
6.6
Malaysia……………………………………………………………………………….....
122
3
6.7
China……………………………………………………………………………………..
123
6.8
Philippines…………………………………………………………………………….....
125
6.9
Iran/ Iraq (Other Southern and Central Asia)…………………………………………....
127
6.10
Egypt……………………………………………………………………………………..
128
6.11
Key findings……………………………………………………………………………...
129
Section 7: International Students as a Health Workforce Resource………………...
131
7.1
International students and skilled migration – the policy context……………………...
131
7.2
International enrolments in Australian medical and allied health degrees……………
131
7.3
Source countries and training institutions………………………………………………
134
7.4
Skilled migration outcomes for former international students…………………………
136
7.5
Employment outcomes compared to domestic graduates……………………………...
140
7.6
Employment outcomes for international medical and allied health graduates compared to all other fields…………………………………...........................................
145
7.7
Case study – former international medical students in Australia………………………
147
7.8
Attracting and retaining international students…………………………………………
152
Section 8: The Challenge of Retaining Migrant Health Professionals……………....
153
8.1
The emigration of health professionals from Australia……………………………….....
153
8.2
The hyper-mobility of international medical graduates……………………………….....
155
8.3
Case study 1 - New Zealand……………………………………………………………..
159
8.4
Case study 2 – Canada…………………………………………………………………...
162
8.5
Conclusion…………………………………………………………………………….....
165
Section 9: Policy Issues and Research Priorities……………………………………...
166
9.1
Key policy issues………………………………………………………………………...
166
9.2
Future research priorities………………………………………………………………...
170
Endnotes and References…………………………………………………………….....
172
4
Acknowledgements
This study was commissioned by Health Workforce Australia (HWA) to assess the scale and impact of health workforce migration on Australia in recent years, including the characteristics of those most likely to proceed to professional practice. I would like to express my sincere appreciation of the following individuals, who made important contributions to the final report. Firstly, my thanks go to Mark Cormack and Ian Crettenden of HWA, with whom I regularly liaised in relation to the scope and focus of the study. I also affirm the valuable feedback received from the Honourable Jim McGinty, Chair of the HWA Board, following review of this paper‟s Preliminary Draft. Secondly, it has been a challenging task to secure data from an unprecedented array of sources of relevance to health workforce migration. In particular I would like to express my appreciation of the contribution made by James Inglis, Sam Tudman, Sarah Ambrose and Janine DeKorte – Health Workforce Australia‟s in-house research staff, with whom it was a pleasure to work in relation to complex requirements. By agreement, data were requested by HWA to my specifications from a range of external bodies. Based on these data HWA staff developed a range of tables for my analysis, the exception being select 2006 Census tables I had previously prepared for UNESCO (sourced); all Occupational English Test, Graduate Destination Survey and Medical Schools Outcomes Database tables (prepared by my colleague Anna To at the University of Melbourne); Australian Medical Council data (tables provided by the AMC); and tables provided by select other regulatory bodies to the researcher (the Australian Nursing and Midwifery Council, the Australian Dental Council, and the Australian Physiotherapy Council). Thirdly, I‟d like to thank the following individuals from external bodies who provided statistical data and/ or key informant perspectives related to health workforce migration across the eight month period of this study. They deeply informed my understanding of the issues: David Smith, Peter Speldewinde, Michael Willard and Mark Cully (Department of Immigration and Citizenship) Ian Frank (Australian Medical Council) Dr Robert Broadbent (Australian Dental Council) Amanda Adrian and Mark Braybrook (Australian Nursing and Midwifery Council) Margaret Grant (Australian Physiotherapy Council) Lyn LeBlanc (Australian Pharmacy Council) Alison Deacon, Gerrard Neve and Josh O‟Connell (Centre for Adult Education – Occupational English Test) Claire Austin, Sharon Kosmina and Karen Argo (Rural Workforce Agency, Victoria) Belinda Bailey (Rural Health West)
5
Dr Ian Cameron (NSW Rural Doctors Network) Chris Mitchell (Health Workforce Queensland) Margaret Proctor (National Office of Overseas Skills Recognition – Australian Education International, Department of Education Employment and Workplace Relations) and Jane Press (Department of Employment, Education and Workplace Relations) Martin Fletcher, Chris Robertson and Jenny Collis (Australian Health Practitioner Regulation Agency) Ian Hawke (Tertiary Education Qualifications and Standards Agency) Sue Beitz (Skills Australia) Dr Philip Pigou (Medical Council of New Zealand) Health Workforce New Zealand (several officers) Professor Richard Bedford (Auckland University of Technology) Dr Ian Bowmer (Medical Council of Canada) Corinne Prince St-Ammand (Citizenship and Immigration Canada) Professor Arthur Sweetman (McMaster University) Nick Kominos (Medical Schools Outcomes Database and Longitudinal Tracking Project, Medical Deans Australia and New Zealand Inc.) Finally, I would like to express warm appreciation to my colleagues in the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne – Anna To, for her meticulous analysis of the Occupational English Test, Graduate Destination Survey, and the Medical Schools Outcomes Databases; Associate Professor Graeme Hawthorne, for his preparation of select 2006 Census tables; Alison Langley and Anna To, for their analysis with me of 14 years of successive Department of Education Employment and Workplace Relations international student enrolment data (Australia-wide); Claudia Sandoval, for her excellent assistance in scheduling and transcribing select interviews, as well as final formatting; and the University of Melbourne Institutional Planning, Evaluation and Quality group, for permitting access to their national Graduate Destination Survey dataset for my analysis for this study.
6
Executive Summary Tables Table 1: Permanent Immigration Intakes to Australia by Major Category Table 2: Permanent Health Professional Migration – GSM Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10, and 2004-05 to 2009-10 Grand Total) Table 3: Temporary Health Professional Migration – 457 Temporary Visa Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10 Arrivals and Grand Total)
15 20 21
Full Report Tables Table 1: Participation Rates of Permanent Resident Undergraduate Medical Students in Australia aged 15 to 24 by Select Country of Birth: 1993 Table 2: Level of Australian and Overseas Born Persons Holding Post-School Qualifications (2006), Migrants Grouped by Time of Arrival in Australia, percentages Table 3: Australian Professional Workforce (2006) by Qualification Level and Field, Birthplace and Year of Arrival, percentages Table 4: Permanent Immigration Intakes to Australia by Major Category Table 5: Australian Employer Sponsorship of 457 Visa Long-Stay Workers by Sector (2006-07 to 2007-08) Table 6: Top 10 Source Countries for Migrant Health Professionals Selected Under the General Skilled Migration Program (2004-05 to 2009-10) and the 457 Temporary Program (2005-06–200910) Table 7: State/Territories of Intended Residence, Settler Arrivals 1998-99 and 2008-09 (All Fields) Table 8: Australian Medical Schools Established by March 2006 Table 9: Medical Students by Type by Student Place: Number of Places (2006-10) Table 10: Australian Medical and Allied Health Course Completions (2001-09) Table 11: Scale of Skilled Migrant Arrivals by Year, Qualification Level and Select Field (2006 Census) Table 12: Qualification Level of Employed Medical and Allied Health Qualified Migrants in the Workforce by Major Field (2001-06 Arrivals) Table 13: Location of 2001-06 Migrant Health Professionals by Key Field by Rank Order (2006) Table 14: Australia‟s Sponsorship of Temporary Nurses by State/Territory by Rank Order (457 Visa Category 2007-08 and 2008-09) Table 15: General Skilled Migration Arrivals - Health Professional Primary Applicants by Field and Place of Selection (2004-05 to 2009-10) Table 16: Labour Market Outcomes for Degree-Qualified Australia/New Zealand-Born Medical Graduates, Compared to Migrant Medical Graduates Arriving 2001-2006 (2006) Table 17a: Permanent Health Professional Migration – GSM Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10, and 2004-05 to 2009-10 Grand Total) Table 17b: Temporary Health Professional Migration – 457 Temporary Visa Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10 Arrivals and Grand Total) Table 18: Employment Outcomes and Profession of Primary Applicant by Field for Health Professionals Selected by Skilled Compared to Family Categories (CSAM 2008-09) Table 19: Employment Status of Australia/New Zealand Degree-Qualified Nurses, Compared to Overseas-Born Nurse Arrivals 2001-2006 (2006 Census) Table 20: Employment Status of Australia/New Zealand Degree-Qualified Dentists, Compared to Overseas-Born Dentist Arrivals 2001-2006 (2006 Census)
7
41 42 43 44 48 51 52 54 56 56 60 61 62 63 64 66 68 68 70 72 74
Table 21: Top 20 Source Countries for Migrant Health Professionals to Australia, Selected through the General Skilled Migration Program, Primary Applicants (2004-05 to 2009-10) Table 22: Top 20 Source Countries for Migrant Health Professionals to Australia, Selected through the 457 Visa Program, Primary Applicants (2005-06 to 2009-10) Table 23: Occupational English Test Pass Rates by Region of Origin, Field of Training (1991-1995) Table 24: Occupational English Test Attempts by Key Field (2005-2010) Table 25: Occupational English Test Outcomes by Country of Training (2005-2010) Table 26: MCQ Pass Rate by Region and Age Tertile (1978-2005 Australian Medical Council Examination Candidates) Table 27: Clinical Examination Pass Rate by Region and Age Tertile (1978-2005 Australian Medical Council Examination Candidates) Table 28: Australian Medical Council MCQ and Clinical Examination Outcomes by Select Country of Training (1 January 1978 to 31 December 2010) Table 29: Australian Medical Council Clinical Examination Outcomes by Top 10 Countries of Training (2004- 2010) Table 30: AMC Competent Authority Pathway Outcomes by Age of Applicant (2007-2010) Table 31: AMC Competent Authority Pathway Outcomes by Top 10 countries of Training (20072010) Table 32: AMC Specialist Assessment Pathway Outcomes by Top 10 Countries of Training (20042010) Table 33: AMC Specialist Assessment Pathway Outcomes by Top 10 Specialties (2004-2010) Table 34: Australian Nursing and Midwifery Council Applications and Assessment Outcomes for General Skilled Migration (2007 to 2010) Table 35: Australian Dental Council Applications and Assessment Outcomes for Registration (2000 to 2010) Table 36: Australian Physiotherapy Council Assessment Outcomes for Migrant Physiotherapists Who Obtained their APC Certificate (2007 to 2010) Table 37: Labour Market Integration Rates for Migrant Medical, Nursing and Dental Professionals in the First 5 Years Post-Migration (2006 Census) Table 38: Scale of Health Workforce Migration by Select Birthplace, by Period of Arrival (2006 Census) Table 39: Growth in Undergraduate International Student Enrolments in Australian Universities in the Medical/Health Sciences: 1996-2009 Table 40: Trends in International Student Demand for Australian Medical and Allied Health Courses by Major Source Countries (2009) Table 41: Top 10 Source Countries for UG and PG International Students in Australian Dental Science Courses (2000 and 2009) Table 42: Top 10 Source Countries for UG and PG International Students in Australian Medicine Courses (2004 and 2009) Table 43: Top 10 Source Countries for UG Post-Basic and PG International Students in Australian Post-Basic Nursing Courses (2000 and 2009) Table 44: Top 10 Source Countries for UG and PG International Students in Australian Physiotherapy Courses (2000 and 2009) Table 45: Top Institutions of Training for International Students Enrolled in Australian Entry to Practice Medical Courses (2009) Table 46: Top Institutions of Training for International Students Enrolled in Australian Basic Undergraduate Nursing Courses (2009) Table 47: Top Institutions of Training for International Students Enrolled in Australian Post-Basic
8
78 79 81 83 85 92 93 96 97 99 99 101 102 109 111 113 116 118 133 134 135 135 135 136 136 137 137
Undergraduate Nursing Courses (2009) Table 48: Top Institutions of Training for International Students Enrolled in Australian Undergraduate Dental Courses (2009) Table 49: Employment Status of Skilled and Family Primary Applicants by Australian Qualification and Grant Location (for Migrants Selected March 2008 to October 2009) Table 50: Intention to Stay in Australia Following Medical Graduation (MSOD 2009) Table 51: Employment Outcomes for Former International Medical Students in Australia Compared to Domestic Graduates Four Months Following Course Completion (2006-2010) Table 52: Employment Outcomes for former International Nursing Students in Australia Compared to Domestic Graduates four Months Following Course Completion (2006-2010) Table 53: Employment Outcomes for former International Dental Students in Australia Compared to Domestic Graduates four Months Following Course Completion (2006-2010 Table 54: Employment Outcomes for Former International Physiotherapy Students in Australia Compared to Domestic Graduates four Months Following Course Completion (2006-2010) Table 55: Median Annual salaries ($AUD) for Australian Graduates Working Full-Time in Australia by Select Field, Domestic compared to Non-Permanent Resident (2006-2010) Table 56: Victorian Internship Destinations for International Students Graduating from the University of Melbourne MBBS Degree (2005-2009) Table 57: Victorian Internship Destinations for International Students Graduating from the University of Melbourne MBBS Degree (2011 for 2010 Graduates) Table 58: Emigration of Health Professionals from Australia, by Gender and Age (2004-05 to 200910) Table 59: Emigration of Health Professionals from Australia, by Country of Birth (2004-05 to 200910) Table 60: Emigration of Australia-Born and Migrant Health Professionals from Australia, by State/Territory (2004-05 to 2009-10 Table 61: Relocations Reported by a Random Sample of IMG‟s in the Interview Research Sample Table 62: The Scale of Health Workforce Migration to Canada 2007 and 2008 – Skilled category Permanent and Temporary Residents by Field.
9
137 139 141 142 143 144 145 146 148 149 153 154 155 157 164
List of Acronyms ACRRM ADC AHMC AHPRA AMC ANMAC APC APC ATS BST CAOP CaRMS CE CSAM DEEWR DoHA DIAC ECFMG EP ESB FICPI GDS GSM HWA IDG IELTS IEN IMG LSIA MCQ MODL MSOD NESB NFEC NLF OET OTD OTP PA PB PBA PESCI PG PR RACGP RACS RWAV
Australian College of Rural and Remote Medicine Australian Dental Council Australian Health Ministers Conference Australian Health Practitioner Regulation Agency Australian Medical Council Australian Nursing and Midwifery Council Australian Physiotherapy Council Australian Pharmacy Council Advanced Surgical Training Basic Surgical Trainee Competency Assessment of Overseas Pharmacist Canadian Resident Matching Service Clinical Examination Continuous Survey of Australia‟s Migrants Department of Employment, Education and Workplace Relations Department of Health and Ageing Department of Immigration and Citizenship Educational Commission for Foreign Medical Graduates Entry to practice English Speaking Background Fitness for Intended Clinical Practice Interview Graduate Destination Survey General Skilled Migration Health Workforce Australia International Dental Graduate International English Language Testing System Internationally educated nurses International medical graduate/s Longitudinal Survey of Immigrants to Australia Multiple Choice Questions Migration Occupations in Demand List Medical Schools Outcomes Database Non-English Speaking Countries National Forensics, Ethics and Calculations Not in labour force Occupational English Test Overseas Trained Doctor Overseas Trained Psychiatrist Primary Applicant Post Basic Pharmacy Board of Australia Pre-employment Screening Clinical Interview Post Graduate Permanent Resident Royal Australian College of General Practitioners Royal Australasian College of Surgeons Rural Workforce Agency Victoria
10
TOEFL TR
Test of English as a Foreign Language Temporary Resident
11
Executive Summary 1. Health Workforce Migration – The Global Context 1.1 Global Demand for Migrant Health Professionals Eight key factors drive the global recruitment of migrant health professionals1. „First, medical and allied health workforces are rapidly ageing in developed countries. As early as 2003, for instance, 42% of Australia‟s surgeons were aged 55 years or more, with the average age of nurses around 502. Second, health workforce migration is a panacea for short-term domestic shortages. In 2000, for example, the UK‟s National Health Service signed bilateral agreements with India, the Philippines and Spain to contribute to the recruitment of 9,500 medical consultants, 20,000 nurses and 6,500 allied health professionals, while domestic training was being scaled up. By 2005, in consequence, 65% of staff grade doctors, 59% of associate specialists and 43% of senior house officers were „third country trained‟ (derived from beyond the UK and the European Economic Area.)3. Third, international health graduates are sought to compensate for sustained outmigration. In New Zealand, for example, recruitment of 2.3 million migrants in 50 years translated to a net population gain of just 208,000 people. By 2010 1,100 international medical graduates (IMG‟s) were being registered annually compared to just 300 domestic graduates. Fewer than half these IMG‟s would remain for a year, dropping to 31% within a 3 year period4. South Africa has developed a comparable level of dependence on migrant health professionals, to compensate for sustained outflows to the United States, the United Kingdom, Australia, Canada and New Zealand5. Fourth, health workforce recruitment has evolved as a tool to address workforce maldistribution and under-supply. The US, for instance, has a disproportionate reliance on IMG‟s to fill inner-city public sector Medicaid posts6, while in Australia and Canada thousands of IMG‟s and nurses each year are recruited to work in „areas of need‟ – regional and remote sites where visas can be tied to specific locations7. Fifth, countries with limited domestic capacity seek expatriates to provide primary and specialist health care, constituting up to 80% or more of recent physicians in the Gulf States and Botswana. Sixth, vast numbers of health professionals from developing countries seek improved life choices for their children – relocating to OECD nations through single or sequential moves designed to secure better career opportunity, remuneration, and professional conditions (migrating for example from India to the Gulf States to South Africa to Australia within a decade). Seventh, migrant health professionals relocate globally as part of family reunification or refugee flows, a process covering the majority of migrant physicians reaching Germany and the Netherlands for instance, in a context where their presence and workforce 12
contribution have not been sought8. (In the case of the Netherlands recent refugee flows have included doctors from the former Yugoslavia, Iran, Iraq, Afghanistan and Somalia.) Finally, what might be termed a „free trade‟ in physicians and allied health professionals exists between OECD countries – major motivations for migration including improved lifestyle, „adventure‟ medicine, and career development. An example is the thousands of UK-trained doctors and nurses accepted by Australia and New Zealand each year, including recently graduated „backpacker doctors‟. A second is the constant shifts south by Canadian health professionals, for example with 8,990 Canadian IMG‟s working in the US by 2005, along with 40,838 IMG‟s from India, 6,687 from China and 3,439 from the UK9.‟ In the context of global maldistribution and undersupply, the majority of OECD countries are in the process of: 1. Developing migration categories designed to attract and retain skilled workers; 2. Monitoring and replicating successful competitor models, including mechanisms for selection and control; 3. Expanding temporary entry options, targeting international students and employersponsored workers; 4. Facilitating student and worker transition from temporary to extended or permanent resident status, supported by priority processing and uncapped migration categories; 5. Combining government-driven with employer-driven strategies; 6. Creating regional settlement incentives designed to attract skilled migrants, supported by lower entry requirements and policy input from local governments and/or employers; and 7. Supporting the above strategies through sustained and increasingly innovative global promotion strategies10. Given this, Australia is certain to face escalating competition to attract and retain health migrants in the future. (See Section 8.)
2. Australia’s Skilled Migration Policy Context 2.1 Level of Reliance on Migrant Health Professionals In recent decades Australia has developed an extraordinary level of reliance on migrant health professionals, to address workforce maldistribution and undersupply. As affirmed by an OECD global scan: Very few countries have specific migration policies for health professionals. Australia is one major exception. The medical practitioner visa (subclass 422) allows foreign nationals… to work in Australia for a sponsoring employer for a maximum of four years. Since April 2003, however, medical practitioners can also apply to the general program for Temporary Business Long Stay (subclass 457). Australia also has specific programmes for attracting foreign health professionals to specific areas. The federal government identifies ‗Districts of Workforce Shortages‘ and states define ‗Areas of need‘ in which foreign-trained doctors may be recruited, temporarily or permanently, sometimes under conditional registration… More generally, there are specific programmes for designated areas (visa 496 or 883) when an occupation is included in the relevant shortage list, which will be generally the case for 13
health professionals. In these designated areas overseas students who have completed their studies in Australia but are unable to meet the pass mark as an independent migrants may be granted a permanent visa (visa 882)11. Three case studies illustrate the scale of demand and the significance of location. By 2010, according to the Rural Workforce Agency, Victoria, 36% of the 1,209 general practitioners (GP‟s) working in rural and remote Victoria had obtained their basic medical qualification outside Australia, primarily in South Asia (11%), the UK/Ireland (7%), Africa (5%), Eastern Europe (4%) and the Middle East (3%), including all vintages of arrival. As early as 2007, IMG‟s constituted 52% of rural and remote GP‟s in Western Australia, derived from 33 countries of training – most notably the UK (24%), South Africa (20%), India (14%), Nigeria and the Netherlands. By 2010 this had risen marginally to 53% - double the level of reliance in 2002. In 2010, according to Health Workforce Queensland, 46% of doctors in rural and remote practice were overseas-trained - primarily qualified in the UK (20%), India (15%), South Africa (12%), the Philippines, New Zealand, Pakistan and Sri Lanka12. While many were permanent residents, the majority were likely to have been 457 visa (or equivalent) temporary sponsored arrivals. As with medicine, Australia has had a longstanding dependence on migrant nurses to compensate for chronic nurse shortages, due to the continued exodus of Australian nurses overseas and to emerging opportunities in other professions. As early as 1983-84 to 1994-95, for instance, 30,544 migrant nurses were accepted by Australia on either a permanent or a temporary basis. This counter-balanced the departure overseas of 23,613 nurses who were locally trained and 6,519 migrant nurses (yielding a net gain of just 412 nurses in all)13. By 2008-09, based on analysis of Department of Immigration and Citizenship (DIAC) data, Victoria was the major importer of temporary nurses (1,010 that year), followed by Queensland (780), Western Australia (750) and NSW (610). Migrant health professionals‟ contribution to regional and remote practice remains critical. Many also provide essential services in urban public sector sites.
2.2 Australian Skilled Migration Policy in the Recent Decade (All Fields) Australia is a global exemplar of nation-building through government planned and administered skilled, family and humanitarian migration programs. The scale of skilled migration has grown rapidly in recent years, now constituting 60% of permanent intakes14. In 2009-10 108,100 permanent migrants were selected in the General Skilled Migration (GSM) category, compared to 27,550 in 1996-97. By 2006 Australia had the world‟s highest percentage of foreign-born (24% of the population), followed by New Zealand (23%), Canada (20%), and the US (11%). In 2009 the population stood at 21,875,000 people, following the largest annual growth in 20 years (a net gain of 443,100 people). Immigration was the primary cause, despite domestic fertility rates rising to 2%. Between 2004-05 and 2008-09, 358,151 skilled category migrants were admitted to Australia (including dependents). Few were derived from the major English speaking background countries. Eight of Australia‟s top 10 GSM source countries at this time were in Asia – in rank order India, China, the United Kingdom, Malaysia, Indonesia, Sri Lanka, the Republic of Korea, South Africa, Hong Kong SAR and Singapore, when English speaking background migrants constituted just 17% of the total. For 2010-11 Australia‟s permanent migration target was set at 190,300 people. Sixty percent of places were allocated to GSM migrants (around 118,000), 32% to the family category, and 8% to humanitarian entrants. (See Table 1.)
14
Table 1: Permanent Immigration Intakes to Australia by Major Category Program Numbers by Stream Family Skilled Additional Skilled* Special Eligibility Humanitarian
1996-97
1998-99
2001-02
2006-07
2007-08
2008-09
2009-10
44,580 27,550
32,040 35,000
38,090 53,520
50,080 97,920
49,870 108,500
56,500 115,000
60,300 108,100
1,730 11,900
890 11,356
1,480 12,349
200 13,017
220 13,000
300 13,500
300 13,750
2010-11 Plan 54,550 113,850 c5,000 300 13,750
Source: Adapted from data in Department of Immigration and Citizenship, “Reform of Australia‟s Skilled Migration Program and Key Inflows: We‟ve Checked Our Policy Settings – Now What?”, May-June 2010, Canberra; and Koleth, E (2011), „Budget 2011-11: Immigration‟, Parliament of Australia, http://www.aph.gov.au/library/pubs/rp/BudgetReview2010-11/ImmigrationPrograms.htm, accessed 21 August 2011*.
An additional 100,000-110,000 migrants are selected annually on an employer-sponsored basis, through the uncapped 457 long-stay visa program which allows temporary migrants to work for up to 4 years. Temporary source countries differ substantially to those of the GSM program, reflecting employer preference. Australia‟s top 10 recent birthplaces have included five English speaking background countries (the UK, South Africa, the USA, Ireland and Canada), plus 2 in western Europe (Germany and France) – by definition countries with directly comparable development levels and training systems.
2.3 Sub-National Competition for Skilled Migrants The global recruitment of migrant professionals constitutes one major challenge. Facilitating their dispersal across Australia is another. Like Australians, migrants habitually settle in highly skewed sites - in particular capital cities associated with jobs, settlement services, networks, ethnic infrastructure and urban amenity. (An identical pattern prevails in New Zealand and Canada.) As demonstrated by the 2006 Census analysis, 2001-06 arrivals were primarily attracted to NSW, Victoria, Queensland, and Western Australia, with few migrant professionals settling in other states. In 2008-09 NSW attracted the largest national migrant share (30% of total arrivals compared to 42% a decade earlier), followed by Victoria (25%), with rapid recent gains made by the mineral-rich states of Queensland and Western Australia15. Queensland for example has become disproportionately dependent on migrants in terms of population size – the destination of 1,343 recent international medical graduates compared to 1,489 in NSW and 1,032 in Victoria. The remaining states/territories attract minute immigrant shares, regardless of their sustained aspirations for growth and important historic ethno-specific concentrations. The Department of Immigration and Citizenship is currently intensifying its efforts to distribute skilled migrants. State/territory sponsored migrants have long been permitted to enter Australia with significantly lower points16. The number selected by states doubled from 8,020 in 2004-05 to 14,060 in 2008-09, with annual targets of 24,000 set for 2010-11 and 2011-12 (all fields)17. By mid-2011 seven state/territory regional sub-categories existed, constituting a third of the total permanent General Skilled Migration stream. South Australia‟s 2010 plan, for instance, included a list of 113 preferred occupations. Virtually every health profession was sought, the great majority requiring degree-level qualifications18. Subnational governments are in the process of being allocated unprecedented policy and operational powers. Since 2010 they have been ranked second and third for priority GSM processing (after employer-sponsored migrants). States/territories have also been commissioned
15
to develop skilled migration plans to be coordinated by DIAC, with skill levels and „leakage‟ across state boundaries to be monitored.
2.4 The Role of Skilled Migration in Relation to Domestic Workforce Supply The Federal government affirms skilled migration to remain a national priority for Australia in the coming period (all fields), within the following context: Long-term workforce demand will be met through greatly expanded domestic training (most notably through 40% of the youth cohort becoming bachelor degree qualified)19. Medium-term demand will be met through the General Skilled Migration program. Short-term demand will be addressed through employer and state/ territory sponsored labour migration programs - most notably the uncapped 457 long-stay visa (where employment offers can be tied to specific locations for up to 4 years). In terms of health, the Australian Health Ministers have set a goal for domestic self-sufficiency by 2025. The policy imperative is thus to recruit migrant professionals able to contribute effectively within the next 13 years. Health Workforce Australia has been charged by the Australian Health Ministers‟ Conference to develop a National Training Plan. Specifically, its aim is to provide: … the estimated numbers of professional entry, postgraduate and specialist trainees that will be required between 2012 and 2025 to achieve self-sufficiency. Self-sufficiency is defined as a situation in which all of Australia‘s requirements for medical, nursing and midwifery professionals in 2025 can be met from the supply of domestically trained graduates without the need to import overseas trained doctors, nurses and midwives to meet a supply gap20 The scale of Australia‟s interim dependence is high. According to the Australian Institute of Health and Welfare, for instance, by 2009 24.5% of Australia‟s 72,739 medically employed workforce was overseas-trained, including 6% of doctors from the UK/Ireland, 3% from New Zealand, and 16.4% (or 11,948) from „other countries‟. The majority of these international medical graduates (all sources) were concentrated in NSW (5,829), Victoria (3,829), Queensland (3,025), Western Australia (2,858), and South Australia (1,681), with minuscule numbers practising in other territories or states. In 2008-09, based on state and territory medical board/ council data, 17,141 doctors (including IMG‟s) were employed under various forms of conditional registration, most notably in NSW (6,100), Victoria (3,971) and Queensland (2,803). This category covered medical practitioners „not meet(ing) the requirements to become a generally registered medical practitioner‟. Further, 2,695 IMG‟s were employed through „area of need‟ registrations (primarily in Queensland, with 1,351) in a context where Australia had become disproportionately reliant on medical migrants for primary health care in outer regional and remote/ very remote sites21. It is important to acknowledge in relation to the analysis to follow that Australia has dramatically increased domestic health workforce supply in the past decade, while attempting to address maldistribution and under-supply. Most notably: Medical Schools: Enrolments in existing medical schools have expanded, with new schools established in New South Wales (Western Sydney, Wollongong, Notre Dame Sydney), Queensland (Griffith, Bond, James Cook), Victoria (Deakin), the Australian Capital Territory (ANU), and Western Australia (Notre Dame Fremantle) 22.
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Domestic medical graduations: By 2006 8,318 Commonwealth supported students were enrolled in medical degrees, rising to 11,873 in 2010, while the number of domestic full-fee medical students doubled (from 405 to 905). In consequence domestic student graduations in medicine rose from 1,203 in 2001 to 1,915 in 2009. Domestic allied health graduations: Rapid growth has also occurred in nursing (graduations rising from 5,084 in 2001 to 7,266 in 2009) and in dentistry (164 graduations in 2007, compared to 416 by 2009, noting earlier data were not provided)23.
3. The Study Focus 3.1 Adult Versus Child Migration Pathways Within this policy context, Australia has relied on five major sources of migrant health professionals to boost supply - the focus of the present study. As will be demonstrated, these migrants are associated with highly variable employment outcomes: 1. New Zealand health professionals – Characterised by free entry to Australia and full qualification recognition under the terms of the Trans-Tasman Agreement. 2. Permanent skilled migrants - Selected as primary applicants on the basis of human capital attributes through Australia‟s points-tested General Skilled Migration Program. 3. Temporary labour migrants - Sponsored by employers through Australia‟s 457 long-stay visa program to fill designated positions for up to 4 years. 4. The dependents of skilled migrants, plus family and humanitarian category arrivals – Selected in non-labour categories, arriving unfiltered in advance for human capital attributes. 5. Former international students - Qualified in Australian medical and allied health degrees, who convert status to remain through a process termed „two-step migration‟. It is important to acknowledge that a sixth migration-related workforce resource exists, which will not be further examined here. By 2006, according to the Census analysis, 45% of Australia‟s medical workforce was overseas-born, compared to 53% of dentists and 25% of nursing graduates1. By definition substantial numbers had arrived as children and qualified with local degrees (a notable success of Australia‟s post-war mass migration program)24. By the mid 1990s 40% of domestic students in Australian medical courses were overseas-born. A striking 24% were derived from Asia - six times the Asia-born proportion in the overall population, compared to just 7% in total from Europe, the UK/Ireland, and the former USSR/Baltic States. These health professionals represent a valuable component of the Australian health workforce, but face no labour market barriers. They are therefore not further investigated here.
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It should be noted that public estimates of the proportion of migrant health professionals in the Australian workforce and overseas-trained are substantially lower than these figures (generally around 25% for medicine and 12% for nursing – for example as assessed by the Productivity Commission in 2005 and by the Australian Institute of Health and Welfare in 2004 and 2010). By definition not all overseas-born doctors and nurses are working at a given point in time. There are also significant numbers of recent arrivals, retirees, and those „not in the labour force‟ for family and/or pre-accreditation reasons. For the most recent estimates see Australian Institute of Health and Welfare (2011) analyses of the medical, nursing and dental labour forces.
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The focus of the current study is recently arrived overseas-trained migrants, in the context of rapidly accelerating recent flows. Further, the study assesses recent Australia-trained international students and their immediate workforce contribution.
3.2 Methodological Challenges A number of methodological issues should be noted in relation to the research findings: Highly variable levels of data are sought/ kept in relation to the different immigration categories. The greatest level of information (including occupational and demographic characteristics) is available for primary applicants selected in the General Skilled Migration category - migrants filtered by DIAC on the basis of their employment attributes. Far more limited data are available for GSM dependents - despite many partners having comparable education and employment skills, and an intention to work. Modest data are available for 457 visa temporary health professionals (including age and gender, and for the 2004-05 year of arrival). Very little is known of their partners, despite these being accorded the right to work. Least data are available for family and in particular humanitarian category entrants, approved for entry to Australia on the basis of relationship or perceived need. Given this, the most comprehensive source of attributes and occupational data for migrant health professionals is the Australian Census – last collected by the Australian Bureau of Statistics (ABS) in 2006, and capturing all permanent as well as temporary residents. Multiple additional databases were sourced (a range never previously analysed for health workforce planning purposes). Indeed, a comprehensive analysis of health workforce immigration to Australia is long overdue. As noted in a recent assessment of health workforce supply by the Australian Institute of Health and Welfare: New entrants to the workforce are mainly from the education system and skilled immigration. Departures from the workforce include migration, resignations, retirements and death. Not all these elements of workforce supply can be accurately measured. For example current health workforce migration data are not considered to be of sufficient quality to provide a reasonable measure of this component25. The aim of the present study is to provide a more definitive level of analysis on immigration and emigration than attempted to date. Within this context, the study focused on the 5 key sources of health workforce supply. (For greater detail see Sections 1-2 of the study.)
4. Major Sources of Migrant Health Professionals 4.1 New Zealand New Zealand‟s contribution to the Australian health workforce is large, given the scope for unrestricted Trans-Tasman arrivals. From 1998-99 to 2008-09 221,643 New Zealanders arrived across all qualification fields. Just 69,884 departed that decade, ensuring major human resource gains to Australia. By the time of the 2006 Census 1,163 New Zealand medical practitioners were resident, along with 5,905 nurses and midwives, 196 dentists, and 1,894 other allied health professionals (9,158 health professionals across all vintages of arrival).
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The majority of New Zealand health migrants were university educated (nursing also including 1,616 who were diploma-qualified). Many were recent arrivals, in a context where 1,247 nurses, 240 doctors, 44 dentists and 368 other allied health professionals had reached Australia from 2001 to 2006. By definition few were captured by Department of Immigration and Citizenship statistics.
4.2 Permanent General Skilled Migration Category Selection The General Skilled Migration category is Australia‟s second key source of migrant health professionals, admitting applicants on a permanent resident basis. Since 1999 GSM primary applicants (PA‟s) have been filtered in advance for human capital attributes, with those at risk of delayed or de-skilled employment excluded at point of entry through points-based selection criteria. Key measures have included: Mandatory pre-migration English language testing, with progressively higher standards required (see Section 3). Mandatory pre-migration credential assessment, conducted by the relevant Australian regulatory bodies for each vocational field (see Sections 4-5). Allocation of greatest points weighting to „the core employability factors of skill, age (below 45 years) and English language ability‟, based on establishment of „minimum threshold standards‟ for each of these aspects. Additional points weighting for occupations in demand, in addition to degree-level qualifications correlating to specific (rather than generic) professional fields. Allocation of bonus points for former international students with credentials recently completed in Australia (a minimum of one and subsequently two years). Allocation of further bonus points for recent continuous Australian or international experience in a professional field, for a „genuine job offer‟ in an occupation in demand, for regionally-sponsored applicants (etc)26. GSM Migration Scale by Field In 2009-10 3,940 migrant health professionals were selected as permanent GSM migrants, compared to 2,870 in 2008-09 and 2,480 in 2005-06 (with 2009-10 the peak year). From 2004-05 to 2009-10 a total of 15,940 were admitted, with key trends as follows: Medical practitioners: 1,070 selected in 2009-10 (compared to 450 in 2008-09 and just 180 in 2005-06). Nursing professionals: 1,700 selected in 2009-10 (compared to 1,360 in 2008-09 and 1,470 in 2005-06). Other health professionals: 1,170 selected in 2009-10 (compared to 1,070 in 200809 and 830 in 2005-06) - in particular pharmacists (560 in 2009-10), dentists (180 in 2009-10), and physiotherapists (130 in 2009-10). (See Table 2.) Major Source Countries It is important to note that 43% of recent GSM health professionals have been derived from English-speaking source countries (in marked contrast to 17% for the GSM program as a whole). Australia‟s top 10 source countries from 2004-05 to 2009-10 were the United Kingdom (4,960), India (1,610), Malaysia (1,470), China (1,030), South Africa (580), the Philippines (570), the
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Republic of Korea (540), Egypt (430), Singapore (470), and Ireland (410). Most selected for admission in 2009-10 were female (63% of the total, reflecting the dominance of nursing). The majority were of prime workforce age (34% aged 25-29 years, 27% aged 30-34, and 16% aged 30-39, while 8% were new graduates aged 20-24 years). (Please note this level of demographic detail was not provided for 457 visa temporary migrants.) Table 2: Permanent Health Professional Migration – GSM Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10, and 2004-05 to 2009-10 Grand Total) Select Field Nursing Medicine Pharmacy Dentistry Physiotherapy Grand Total (All Fields)
GSM 2005-06 1,470 180 300 70 80 2,480
GSM 2008-09 1,360 450 440 130 90 2,870
GSM 2009-10 1,700 1,070 560 180 130 3,940
GSM Total 2004-05 to 2009-10 8,250 2,330 2,080 600 550 15,940
Source: Analysis of unpublished Department of Immigration and Citizenship flows data, provided to HWA.
4.3 Temporary 457 Visa Long-Stay Category 457 Visa Sponsored Selection Despite the scale of General Skilled Migration flows, the 457 temporary visa has been Australia‟s most important recent source of migrant health professionals. 34,870 were selected from 2005-06 to 2009-10, compared to 15,940 for the GSM from 2004-05 to 2009-10 (noting data for the GSM were available a year longer). There are compelling attractions related to the 457 visa: Temporary resident migrants are sponsored by Australian employers, with applications fast-tracked. Their location can be prescribed as a condition of visa entry (facilitating employment in „areas of need‟). Migrants arrive to pre-arranged work, securing immediate employment outcomes in designated positions (with 99% employment rates at 6 months the norm). Health professionals are allowed to work on a conditional or limited registration basis for up to 4 years, with age criteria far less restrictive. As described by the Department of Immigration and Citizenship, The person identified to fill a nominated vacancy… must satisfy the department that they have skills which match those required for the vacancy for which they have been nominated… A skill assessment of the visa applicant is not generally required (unless there are doubts about his/her capacity to fill the position). Where Australian registration or licensing is required to undertake the nominated position, applicants may be asked to provide evidence that they are eligible for the relevant registration or licence. Medical practitioners are required to provide evidence of registration to practise in the state or territory in which they will be working27.
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Migration Scale by Field The 457 visa option has proven highly attractive to migrants, employers and governments. In 2007-08 health and community service workers dominated the category, with 9,090 sponsored admissions (21% growth on the previous year). Australia‟s expansion of „area of need‟ posts in medicine has improved medical distribution to under-served sites. Workforce supply is boosted, despite debate on the conditional registration scheme, which allows thousands of temporary resident IMG‟s to work on a supervised basis. Temporary flows have also had a profound impact on occupational distribution relation to nursing and midwifery. In 2009-10 6,020 migrant health professionals were sponsored by Australian employers on the 457 visa, compared to 8,190 in 2008-09 and 5,300 in 2005-06. From 2005-06 to 2009-10 a total of 34,870 arrived. The scale by field was as follows, trending down from Australia‟s 2008-09 peak of 8,190, at a time when permanent health GSM flows were growing: Medical practitioners: 2,670 in 2009-10 (compared to 3,310 in 2008-09 and 2,120 in 2005-06). Nursing professionals: 2,710 in 2009-10 (compared to 4,070 in 2008-09 and 2,660 in 2005-06). Other health professionals: 640 in 2009-10 (compared to 800 in 2008-09 and 540 in 2005-06), in particular dentists (150 in 2009-10), physiotherapists (90 in 2009-10) and pharmacists (20 in 2009-10). (See Table 3.) Table 3: Temporary Health Professional Migration – 457 Temporary Visa Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10 Arrivals and Grand Total) Select Field Nursing Medicine Dentistry Physiotherapy Pharmacy Grand Total (All Fields)
457 Visa 2005-06 2,660 2,120 90 60 50 5,300
457 Visa 2008-09 4,070 3,310 160 100 20 8,190
457 Visa 2009-10 2,710 2,670 150 90 20 6,020
457 Visa Total 2005-06 to 2009-10 15,960 15,490 660 420 160 34,870
Source: Analysis of unpublished Department of Immigration and Citizenship flows data, provided to HWA.
It is worth noting that few migrant pharmacists have arrived via the 457 visa (160 from 2005-06 to 2009-10) in marked contrast to an extraordinary 2,080 selected from 2004-05 to 2009-10 through the General Skilled Migration category. Major Source Countries Australia‟s 457 visa category demonstrates the strength of employer preference for high-level English ability (including native speakers), comparable health education systems, and perceived capacity to integrate at speed. From 2005-06 to 2008-09 45% of Australia‟s 34,870 sponsored health professionals were derived from the major English-speaking countries (compared to 43% of the GSM). The top 10 source countries were the United Kingdom (9,350), India (6,420), the Philippines (1,850), South Africa (1,770), Malaysia (1,570), Ireland (1,560), China (1,380), Zimbabwe (1,180), Canada (950) and the United States (830).
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It is important to note the 2011 House of Representatives Inquiry into the Registration Processes and Support for Overseas Trained Doctors highlighted systemic problems related to the 457 visa and GSM programs, including a litany of concerns related to red tape, plus IMGs‟ experience of inequitable or prejudicial treatment (important issues that were beyond the brief of the present study)28. As noted in the full report, these issues were powerfully raised by Victorian, NSW and Western Australian key informants consulted in the course of the current study.
4.4 Dependents of Skilled Migrants, and Family and Humanitarian Categories Beyond the General Skilled Migration and 457 visa programs, large numbers of migrant health professionals reach Australia as the dependents of skilled migrants, or within the family and humanitarian categories. The majority arrive unfiltered in advance for human capital attributes, despite permanent resident status and intention to work (recent examples including Iraqi and Myanmar trained doctors). From 2004-05 to 2008-09, for instance, 1,489 international medical graduates (IMG‟s) were selected by Australia as General Skilled Migrants. This number rose to 2,593 once spouses were factored in. The number of nurses grew more modestly when counting partners (from 6,400 to 7,646). As demonstrated by the 2006 Census analysis, the scale of health workforce migration to Australia (across all immigration categories) has increased dramatically in recent years. Between 2001 and 2006: Medicine: 7,596 migrants with medical qualifications were accepted (compared to 4,392 from 1996-2000). Nursing: 6,680 degree-qualified registered nurses and midwives were accepted (compared to 3,100). Dentists: 1,125 dentists were accepted (compared to 540). Large numbers of migrants qualified in other allied health fields were also admitted, including many in the family and humanitarian categories. These migrants were not actively recruited by Australia. As demonstrated by the research evidence, many face severe labour market disadvantage, taking years (if ever) to achieve professional integration. As demonstrated in the 2011 House of Representatives Inquiry into the Registration Processes and Support for Overseas Trained Doctors in relation to medicine, this can be a matter of personal and professional anguish29.
4.5 Former International Students International Student Attributes Australia has a fifth important health workforce resource – former international students, who have qualified in Australia and self-funded to meet domestic employer requirements. By definition former students are characterised by: Youth and long-term productivity (their average age being 24 years). Exemption from English language testing (with IELTS scores of Band 6.5 or 7 required for course commencement). Full medical and allied health vocational registration. Training to Australian professional norms (including through regional as well as urban rotations). Significant acculturation.
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‗Two-Step Migration‘ By 2008 international students were generating $A26.7 billion per year for Australia, in a context where the industry had emerged as the nation‟s third largest, and the first for the state of Victoria30. In 2009 630,552 international students were enrolled in Australian courses – 202,229 in higher education compared to 231,639 in the vocational sector. While VET sector enrolments have plummeted 20% (following the recent introduction of measures to address perverse studymigration incentives), international higher education enrolments have continued to climb - by 16% in the year to March 2011, levelling to 2% to July 2011. The phenomenon of „two-step‟ student migration is now proliferating world-wide. According to an Oxford-based migration researcher: The movement of students should be seen as an integral part of transnational migration systems, not least because the networks they forge often lay the tracks of future skilled labour circulation (… A)mong governments there is growing awareness of this, seen in the increasing incidence of national programmes for students‘ recruitment with a specific view towards longer-term or permanent settlement)31. International Student Enrolments by Select Field The scale of enrolments in Australia by field has grown rapidly in recent years. By December 2009 (the latest available data): Nursing: 6,124 international students were enrolled in baccalaureate nursing degrees (compared to 762 in 1996). A further 2,566 were completing post-basic diploma to degree courses (rising from 545 in 1996). This option was of particular interest to migration-motivated diploma-qualified nurses, for example from India and China (in a context where by 2009-10 35% of GSM category nurses were being sourced onshore). Medicine: 2,772 international students were enrolled in entry to practice medical degrees (based on school-leaver or graduate entry) compared to 963 in 1996. By Semester 1 2011 enrolments had grown to around 3,000, with an estimated 70% of former international students transitioning on graduation to internships32. Dentistry and Physiotherapy: 387 international students were enrolled in Australian entry to practice dental degrees in 2009 compared to 98 in 1996. Figures were similar in physiotherapy, with 369 international students enrolled (compared to 79)33. By 2010, according to a recent study, 242,711 international students were completing Australian university courses (139,902 in bachelor degrees, 80,935 in masters degrees, and 13,355 in doctoral programs). Annual international student commencements in health degrees have continued to rise, from 6,255 in 2008 to 6,993 in 2010, making 18,487 enrolments in all (8% of international students in Australia‟s higher education sector)34. As will be demonstrated, these students represent a significant migration resource for Australia.
5. Major Research Findings 5.1 The Policy Challenge Governance of health workforce migration is challenging, given the growing scale and diversity of intakes. (See Sections 1 and 2 of the report). During the lead-up to domestic self-sufficiency (2025), Federal and state/ territory governments must: 23
Compete in the global recruitment of skills. Define the migrant health professionals most likely to secure vocational registration, including those with a capacity to integrate at speed. Ensure migrants‟ dispersal post-arrival - using domestic policy levers to address workforce maldistribution as well as under-supply; and Enhance national as well as regional retention, in a context where hyper-mobility and on-migration have become global norms. Within this context Sections 3 to 8 of the paper assessed which migrant health professionals are best placed to meet Australia‟s needs. Key findings are summarised below, based on interrogation of a wide range of databases.
5.2 The Impact of Source Country on Early Access to Employment Case Study 1 – Medicine Australia‟s diversification of health migration source countries has proven challenging. As demonstrated by analysis of the Census data (all immigration categories), by 2006 just 53% of recent international medical migrants secured Australian medical employment in their first 5 years. Those with the highest labour market integration rates were derived from South Africa (75% working as doctors), the UK/Ireland and Other Sub-Saharan Africa eg Zimbabwe (both 71%), Singapore and Malaysia (62%), India and Western Europe (61%). Outcomes were poor by contrast for a range of birthplace groups. For example just 6% of doctors from China secured medical employment within the first 5 years, along with 23% from Vietnam and 31% from Eastern Europe. Many had reached Australia within the family and humanitarian categories – unfiltered in advance for English, employment attributes or vocational registerability35. Substantial numbers were defined as „not in the labour force‟ (NLF) by 2006 – a proxy for learning English and attempting to satisfy pre-registration hurdles. Fifty-nine percent of Indonesian doctors fell into the NLF category, in addition to 48% of doctors from Japan/South Korea, 47% from Vietnam, 38% from Eastern Europe, and 36% from China. Case Study 2 – Nursing A comparable pattern was evident in relation to nursing. Between 2001 and 2006 6,680 degreequalified nurses migrated to Australia, compared to 3,100 from 1996-2001 (all immigration categories). The top 5 sources at this time were the UK/Ireland (2,081), the Philippines (1,009), India (455), Japan/South Korea (383) and China (356). Overall 63% of these migrants secured nursing employment within 5 years, reflecting the evolution of bridging programs and sustained workforce demand36. In line with medical migrants‟ outcomes however, birth country/region of origin and English ability proved to be major issues. Nurses from Singapore were swiftly integrated in Australia (86% employed in their profession within 5 years), followed by those from South Africa (79%), and the UK/Ireland (76%). Nurses from Hong Kong/Macau (59%), the Philippines (58%) and China (53%) fared well, but results were far worse for those migrating from Central/South America (31%) and North Africa/ Middle East (33%). Case Study 3 – Dentistry As with nursing and medicine, marked variations in early access to dental employment prevailed for overseas-trained dentists. South Africans moved seamlessly into work (89%), followed by dentists from Malaysia (84% - many former students qualified in Australia), the UK/Ireland
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(82%), North-East Asia and Other Sub-Saharan Africa (both 69%). By contrast labour market barriers were extreme for dentists migrating from India (just 23% securing dental employment in their first 5 years), China (21%) and the Philippines (7%). This represents a serious issue, given the prominence of these source countries in recent dental workforce migration.
5.3 The Impact of Immigration Category The 2006 Census outcomes are depressed by the inclusion of family and humanitarian category health professionals. Employment outcomes by contrast are excellent for sponsored 457 visa migrants (who by definition come to jobs). The permanent GSM program is also a very effective selection tool. Analysis of DIAC‟s Longitudinal Survey on Immigrants to Australia (the LSIA) demonstrated consistently superior employment and salary outcomes were secured in 2005 and 2006 by GSM compared to family category migrants, for whom elongated and less remunerated pathways were the norm. In 2006, for example, 83% of GSM PA‟s were employed at 6 months (all fields), with 53% working in their preferred occupation. By 18 months 89% were employed – just 18% stating they had experienced any unemployment in the previous year. Seventy percent at this stage were working in their preferred occupation, with impressive mobility rates and salary gains also the norm37. (Small cell sizes prevented extension of the LSIA analysis to specific health professions.) Analysis of DIAC‟s Continuous Survey of Australia‟s Migrants (the CSAM) for 2009 and 2010 confirmed GSM medical migrants to achieve strong early employment rates (690 out of the 770 informants working in health, presumably most in medicine), with negligible numbers unemployed or not in the labour force at 6 and 18 months. Similar results were evident for nursing. Family category migrants by contrast (all health fields) experienced dramatically higher unemployment and not in the labourforce rates. Such outcomes were markedly influenced by age and place of qualification. In terms of salaries the CSAM also provided the following outcomes: Medicine: Annual wages reported for skilled category doctors 18 months postmigration were $43,984 to $228,800. The range for family category doctors within the same timeframe was $45,000 to $128,270 (noting rates varied markedly by state). Nursing: A similar pattern prevailed in relation to nursing. The salary range for GSM nurses 18 months post-migration was $35,725 to $59,479. The range for family category nurses within the same timeframe was $22,114 to $41,458. Wage gaps at 6 compared to 18 months: Proportional differences by immigration category were evident for both fields at 6 and 18 months.
5.4 The Impact of Place of Qualification Place of qualification has major impact on employment outcomes. As demonstrated New Zealand trained health professionals are immediately acceptable to Australian employers (native English speakers trained in directly comparable systems, with fully recognised credentials on arrival). Health professionals from the United Kingdom, Ireland, South Africa, Canada and the United States of America are also highly advantaged, along with many professionals from Commonwealth-Asia (trained in British-based education systems, with strong English language exposure).
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International Students‘ Birthplace and Employment Outcomes Compared to Domestic Graduates Former international students qualified in Australia constitute a particularly acceptable health workforce resource - regardless of birthplace or visible minority status. As demonstrated in Section 7 of the report, the great majority to date are derived from Asia (Canada being the major exception). By 2009 Singapore (3,458 students), China (2,283), Malaysia (2,240), India (1,556), the Republic of Korea (1,021) and Canada (932) were the primary student sources, key enrolments by discipline being: Entry to practice medicine: Malaysia (1,134 enrolments), Singapore (577) and Canada (437 – enrolments sharply rising since). Basic nursing: China (1,516 enrolments), India (892), and the Republic of Korea (706). Post-basic nursing (diploma to degree upgrade courses): Singapore (1,188 enrolments), China (224) and Malaysia (223). Physiotherapy: Singapore (104 enrolments), the Republic of Korea (57) and Malaysia (46). Former international students in Australia have emerged as a new skilled migration „elite‟, as demonstrated by analysis of Australia‟s 2006 to 2010 Graduate Destination Survey in consecutive years. They are advantaged relative to skilled category migrants, and far exceed the early employment outcomes achieved by family and humanitarian category entrants. In particular, they achieve comparable employment and salary outcomes to domestic health professionals within 4 months, based on national survey data shortly after graduation. Medicine 675 former international medical students were still resident in Australia and responded to the Graduate Destination Survey from 2006 to 2010. In 2010 87% were in the workforce. Virtually all were employed in medicine full-time (98.9%), compared to 99.7% of available domestic medical graduates. Comparable outcomes prevailed across all 5 survey years. For example in 2006 93% of former students resident in Australia were in the workforce at 4 months. 96.9% of these reported full-time medical work at this time, while 3% continued to seek employment. In terms of salaries, negligible difference was found with domestic medical graduates (just $2,000$3,000 per annum). Former international students, regardless of source country, proved immediately acceptable to Australian employers. Nursing 2,227 former international nursing students responded to the GDS survey from 2006 to 2010, 4 months following graduation (compared to 15,644 domestic graduates). In 2010 73% resident in Australia were available for work. Two-thirds (69.6%) were already employed full-time in nursing, with an additional 20.8% working in the field part-time. (This compared to 93.4% and 4.8% of domestic graduates then in the workforce.) Results were strong across all 5 survey years, with outcomes for 2010 relatively modest. In 2006, for instance, 76.8% of former nursing students resident in Australia were in the workforce. 91.5% of these held full-time nursing positions, with an additional 6.6% employed in the field part-time. A further 7% were enrolled in full-time study, with just 1% still seeking work. In terms of salaries, across all 5 survey years, comparable or higher salaries were achieved by former international students working full-time than domestic nursing graduates (perhaps reflecting the number of hours worked).
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Dentistry 98 former international dental students responded to the GDS survey from 2006 to 2010 (compared to 860 domestic students). 70% of these were available for work in 2010. 93.8% were already employed as dentists full-time, with an additional 6.3% seeking employment. (This compared to 93.6% and 1.6% of domestic graduates.) Results were again strong across all 5 survey years, with outcomes in 2010 relatively modest. For example in 2007 100% of available former students were employed in dentistry full-time, compared to 95% in 2008 and 94% in 2009. In terms of salaries, they achieved marginally lower, comparable or higher salaries than domestic dental graduates at 4 months (depending on year). In 2008, for instance, former international students averaged $95,000 commencing salaries (16 respondents), compared to $80,000 for domestic graduates (596 respondents). This dropped to $76,696 in 2010 compared to $80,000. Physiotherapy Results for former international students qualified in physiotherapy were also examined (141 respondents to the GDS survey compared to 2,644 domestic students). In 2010 70% of those still resident in Australia were available for work. Two-thirds (69.2%) were employed in physiotherapy full-time, with an additional 19.2% working in part-time positions. (This compared to 91.3% and 6.7% of comparable domestic graduates.) Results were again strong across all 5 survey years, with outcomes in 2010 relatively modest. For example in 2006 90% of international students resident in Australia were in the physiotherapy workforce, with 100% employed in physiotherapy full-time. Salaries were virtually identical at 4 months to those achieved by domestic physiotherapy graduates (any year). In 2006, for example, former international students averaged $43,250 commencing salaries compared to $43,000 for domestic graduates. This rose to $47,825 in 2010 (compared to $47,000). As demonstrated in Section 7 of the report, large numbers of former international students wish to migrate – acclimatisation to Australia, access to clinical training positions (in medicine), and perceived opportunity relative to „back home‟ being key motivators. In terms of medicine, for instance, analysis of the Medical Schools Outcomes Database and Longitudinal Tracking Project suggested 69% of recent international medical students were planning to stay, most notably those derived from Brunei Darussalam (89%), Singapore (75%), Malaysia (74%) and Canada (72%). Former international students, like New Zealanders, have satisfied in advance all Australian preregistration requirements. By contrast large numbers of overseas-trained migrant health professionals – particularly those selected in the family and humanitarian categories - struggle to secure full professional registration. Thousands will take years (if ever) to achieve this. English represents the first major barrier.
5.5 The Impact of English Testing on Selection and Vocational Registration Testing Requirements Research in the past decade has demonstrated English to be the key determinant of skilled migrants‟ employment outcomes in Australia. Increasingly the argument has been made that professionals cannot take their place in the knowledge economy if lacking sophisticated English competence. In line with this, the major finding of Australia‟s 2006 skilled migration review (the most detailed in 20 years) was that: ….in most dimensions of labour market success, the key is to have a level of English language competence that enables the respondents to report that they speak English at 27
least ‗very well‘…. (Those who do not) were much more likely to be unemployed; about half as likely as those with better English to be employed in a job commensurate with their skills; and about twice as likely to be employed in a relatively low skilled job38. Migrant health professionals can elect to take either the International English Language Testing System (IELTS) or the Occupational English Test (OET) exams, noting that in dentistry until recently only the OET was accepted. In the past 5 years Australia has required both permanent and temporary migrants to take the test, either offshore for skilled migration selection, or within Australia to secure vocational registration. As demonstrated by the Occupational English Test case study (see Section 3), English language assessment exerts an extraordinary impact on migrant health professionals. This has intensified rather than diminished in recent years, reflecting the introduction of higher English language testing standards, and the requirement for applicants to pass all four language sub-tests at a single sitting (resulting in overall pass rates dropping from 37% in 2005 to 34% in 2010). Language testing requirements are a matter of deep concern, reflected in individual submissions to the House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors (2011)39. The place where the test is taken is significant, along with birthplace, gender, and qualification field. Exemptions have contracted, for example with South African nurses until recently required to take the test. (From September 2011 South Africa has been listed among exempt countries.) OET Outcomes – the 1990s Between 1991 and 1995, when 70% of international medical graduates reaching Australia were from non-English speaking background countries, 2,079 overseas trained doctors sat for the OET at least once. The OET was found to prevent or significantly delay 43% of NESB medical candidates from proceeding to the second and third pre-registration stages - the Multiple Choice Question and Clinical examinations of medical knowledge. The impact of mandatory English language testing was harsher on overseas qualified nurses sitting the test – many of whom had been less exposed to English in the course of their education. From 1991-95 just 32% of nurses passed on their first attempt (compared to 57% of doctors). A mere 47% succeeded on one or repeated attempts (compared to 78% of doctors). Highly differential outcomes by country of origin were evident for both medicine and nursing. OET Outcomes – 2005-2010 In recent years, as noted, 43% of GSM health migrants and 45% of 457 visa health applicants have been derived from the major English speaking countries. Over half both categories have been non-native speakers. English language standards have since been raised by Australia‟s medical and allied health regulatory bodies, requiring International English Language Testing System (IELTS) Band 7 or OET B scores for registration (with „Good User‟ considered the lowest acceptable level for safe practice). The OET currently tests 12 professions: dentistry, dietetics, medicine, nursing, occupational therapy, optometry, pharmacy, podiatry, physiotherapy, radiography, speech pathology and veterinary science. Two key policy issues should be noted in relation to this. First, health regulatory body standards now exceed Australia‟s GSM threshold requirements for English (IELTS Band 6 or the OET equivalent). Second, in 2005 candidates were able to secure the necessary OET grade by passing the speaking, listening, reading and writing modules on
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successive tests. In 2010, by contrast, all four modules had to be passed in a single setting – a far more challenging hurdle. OET examination data were secured and analysed from 2005-2010 to assess the test‟s impact – the first such in-depth analysis40. Within the period studied, 24,683 health professionals had attempted one or more modules of the test, with multiple attempts the norm2. Nursing applicants predominated (9,019 candidates), followed by migrants qualified in medicine (7,160), dentistry (an extraordinary 6,172) and pharmacy (1,752). Test numbers peaked in 2009 at 6,070 before declining to 4,960 in 2010 and 4,241 in 2011. (This decline probably reflects the higher English standards now required, as well as the completion of „backlog‟ testing for temporary migrant health professionals.) OET Outcomes - Test Location, Candidate Field and Gender The OET is administered in 19 countries, in addition to Australia. Place of application significantly influences language testing outcomes – candidates sitting the test in Australia having access to preparatory training (by definition immersed in an English speaking society, and with GSM candidates filtered pre-migration). Results were systematically worse for those taking the OET offshore – just 29% of candidates passing compared to 36% in Australia in 2010. The difference was stark for medically qualified migrants from 2005-10. Forty-seven percent of candidates passed the OET in Australia in 2010, compared to just 29% attempting the test overseas. Gender was also found to have an impact – male candidates marginally out-performing females across test fields (even in nursing). Overall OET pass rates also varied significantly by qualification field. In 2005 there was a 37% average pass rate. Of all tests attempted by dental candidates, 29% were passed in one sitting, compared to 38% of test sittings passed by medical candidates3. The key trend to note is the impact of Australia‟s 2010 requirement for candidates to pass all 4 OET sub-tests at a single sitting. The overall OET pass rate of 37% in 2005 dropped to 34% in 2010. In 2010 72% of all attempted sub-tests were passed by dental candidates, compared to 68% by doctors, 51% by physiotherapists, 46% by pharmacists and just 43% by nurses. However this translated to just 19% of nurses passing overall, compared to 34% of physiotherapists, 43% of doctors, and 47% of dentists. Australia‟s recent policy requirement for all four sub-tests to be passed at a single sitting thus constitutes a more significant barrier. OET Outcomes - Candidate Source Country The highest OET failure rates for 2010 were experienced by health professionals trained in Japan (91%), Saudi Arabia (87%), the Philippines (86%) and Egypt (81%), averaged across all fields, with an average failure rate of 78% of sittings attempted. Candidates trained in South Africa (55% pass rate) were unsurprisingly the most advantaged, but even for these native speakers the requirement to pass all four OET modules at a single sitting proved challenging. Chinese candidates were the sole non-English speaking background group found to have improved their OET outcomes in 2010 compared to 2005 – reflecting the markedly greater exposure to English 2
Within this context please note that a candidate who had attempted all four OET modules twice would have been counted as 2 „candidate‟ attempts, 2 sittings and 8 sub-tests, given the way the data were collected. 3 Reporting the outcomes is somewhat complex. To clarify, taking dentistry as an example, the 32% refers to the number of tests – that is, the pass mark as a proportion of tests attempted; while the 44% refers to the pass mark as a proportion of people who sat the tests.
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now characteristic of China. Overall, the following country of origin groups secured the best candidate pass rates (after re-sitting as required), with results for Filipino (24%) and Egyptian (29%) candidates remaining particularly poor: South Africa: 66% Pakistan: 44% Iraq: 43% Bangladesh: 43% India: 43% Sri Lanka: 40% China: 39% The consistency of these outcomes with 2006 Census employment outcomes is significant. In 2006 5,094 migrant health professionals from India were resident in Australia, compared to 4,638 from the Philippines, and 3,200 from China. Large numbers were recent 2001-06 arrivals, including 2,063 from India, 989 from the Philippines, and 651 from China (the Census by definition capturing all immigration categories). Recent changes in Australian English testing requirements are a matter of deep concern, reflected in individual submissions to the 2011 House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors41.
5.6 Access to Professional Registration General Registration Beyond English language testing, migrant health professionals have highly variable rates of access to vocational registration, with English speaking background and Commonwealth candidates best placed to secure this at speed. (For detailed analysis by field see Sections 4 to 5 of the report. For a synthesis of outcomes by major source country see Section 6, presenting key data for New Zealand, United Kingdom, Ireland, South Africa, India, Malaysia, China, the Philippines, Iran, Iraq and Egypt health professionals.) A wealth of AMC information could be sourced in relation to medical registration applications, allowing analysis of outcomes by age, gender and place of training, and for specialist as well as generalist qualifications. Far less was available for allied health professions. Medical Registration Outcomes The most recent IMG accreditation data can be found in the Australian Medical Council‟s (AMC) 2011 submission to the House of Representatives‟ Inquiry into Registration Processes and Support for Overseas Trained Doctors42. From 1978-79 to 2010-11 33,725 IMG‟s sat for the MCQ exam, including 20,728 new candidates. Fifty percent passed. 15,963 candidates attempted the Clinical exam (10,462 new candidates), with a pass rate of 55%. Success rose with subsequent attempts. By 2010 85% of MCQ candidates passed overall (most in two attempts), and 94% passed the Clinical examination (a comparable pattern). As demonstrated in Section 4 of the report, pass rates by country of training however remained highly variable – reported here for primary countries of training, and with multiple attempts counted. Indian doctors‟ MCQ pass rate was 51%, compared to 79% for doctors trained in the UK/Ireland, 74% in South Africa, 65% in Iraq, and 60% in Myanmar. In marked contrast just 31% of doctors trained in the Philippines passed. Comparable variations were evident in relation to Clinical exam outcomes (for example a Chinese pass rate of 58% compared to 52% for India,
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Iraq and Egypt but 38% for Filipino candidates). Demand for AMC exams however is increasing. In 2009-10 4,466 candidates attempted the MCQ, compared to 1,509 in 2005-06. Clinical attempts similarly rose from 887 to 1,258 within this period. Age was a critical variable in relation to AMC pass rates. From 2004-10 57% of IMG‟s aged 2130 years passed the MCQ on their first attempt, compared to 46% aged 41-50 years and just 31% aged over 50. Similar trends were evident in relation to the Clinical exam. Gender was less important to the MCQ (55% of female candidates passing the MCQ compared to 52% of males) but differences for the second exam were stark (59% of women passing the Clinical on their first attempt compared to 48% of males). Further to these findings, a summary was provided in Section 4 of outcomes from the most extensive Australian study of IMG‟s to date (2007), commissioned by the Department of Health and Ageing. This study included analysis of 1978-2005 AMC examination outcomes by key variables, a mailout survey assessing the registration and work status 3,000 recently arrived IMG‟s, and comparison of IMG‟s registered on the NSW, Victoria and Western Australian Medical Board databases43.
Recent Pathway Innovations It is important to note the significance of new Australian entry to practice pathways which have evolved in recent years, reflecting Commonwealth of Australian Government reforms. The Competent Authority (CA) pathway (introduced in 2007) is a fast-track option developed by the AMC in association with the Queensland Department of Health. It caters to what might be termed the „elite‟ of Australia‟s recent medical migration program44. Within the Competent Authority model, IMGs‟ country of original qualification is deemed less important than their form of accreditation. Based on the research evidence, the CA model recognises that there are „a number of established international screening examinations for the purposes of medical licensure that represent a “competent” assessment of applied medical knowledge and basic clinical skills‟ to a standard consistent with AMC requirements. Four examination and two accreditation systems have been reviewed and approved by the AMC for the CA model of assessment. Global response to the Competent Authority pathway has been positive and immediate, associated with what might be termed transformational recruitment outcomes. Since July 2007 4,955 CA applications have been received, with 3,327 Certificates of Advanced Standing issued. 1,990 applicants from 56 countries of training had successfully completed the process by December 2010, a year in which 1,281 applications for assessment were received. The CA pathway has also greatly enhanced Australia‟s global competitiveness45. From 2007-10 the Competent Authority pathway attracted relatively young applicants, with 54% of those issued Advanced Standing Certificates aged 21-30 years compared to 38% aged 31-40. UK trained applicants were the major beneficiaries (1,019), followed by IMG‟s qualified in India (422) and Ireland (176). Massive recent growth in UK/Ireland qualified arrivals has occurred, surging to around 3,000 in 2007-10, compared to „a trickle‟ per year previously. (Additional medical registration pathways are described in Section 4 of the study.)
Specialist Registration The scale of recent medical arrivals with specialist qualifications is also significant – explored in detail in Section 4 in relation to surgery and psychiatry (fields with longstanding reliance on IMG‟s). From 2004-10 11,612 IMG specialist assessment applications were received by the
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AMC. The majority were from males (69% of the total), with the top 10 specialist countries of training as follows: the UK (3,009), India (2,712), South Africa (1,084), the USA (647), Germany (468), Sri Lanka (372), Ireland (226), Iran (205), Canada (202) and the Philippines (152). Unsurprisingly, IMGs seeking specialist AMC assessment proved to be significantly older than the norm (a trend with productivity implications). 443 candidates were aged 21-30 years, 6,093 aged 31-40 years, 3,876 aged 41-50 years, 968 aged 51-60 years, and 232 aged 61 or older. Those older than 40 years at this time were ineligible to apply for the GSM program. They had almost certainly sought to enter Australia through the temporary 457 visa. Applicant numbers and outcomes varied markedly by field. IMG‟s qualified in anaesthesia (843), psychiatry (747), obstetrics and gynaecology (507), diagnostic radiology (512) and general surgery (391) dominated, with orthopaedic surgery ranked eighth. Recognition outcomes again varied markedly by country of training, with 80% of South African qualifications deemed „substantially‟ or „partially comparable‟ to Australian standards, compared to 76% of UK qualifications, 49% from Canada, 43% from Iran and just 39% from the Philippines. In terms of speciality just 15% of migrant general surgeons were deemed „substantially comparable‟ to Australian qualifications from 2004-10, compared to 20% of psychiatrists and 29% of anaesthetists. Again, barriers confronting overseas trained medical specialists were repeatedly raised in submissions to the 2011 House of Representatives Enquiry, including from major ESB countries (such as South Africa).
5.7 Access to Allied Health Registration Far more limited data are available in relation to migrant allied health professionals, including their level of access to vocational registration. This seems remarkable given the numerical dominance of nurse migration, the scale of recent allied health flows, and rapid recent escalation in pharmacy and dental arrivals. Section 5 examined professional registration trends in relation to nursing, dentistry, pharmacy and physiotherapy. These fields warrant substantial future research, with the current dearth of information on outcomes constituting a serious impediment to workforce planning. Nursing Registration The primary Australian study of nurse migration to date was conducted in the 1990s. Based on a survey of 1,000 overseas qualified nurses who had arrived in the previous decade (719 responses), it excluded nurses who were professionally displaced - focusing on those who had achieved full registration status. While ESB nurses had passed easily into employment, NESB nurses had been obliged to address three major hurdles46. First, mandatory English language testing in the 1990s barred up to 67% of NESB primary applicants from eligibility for GSM migration, and 41% of those reaching Australia from proceeding to pre-registration courses. As demonstrated, OET impacts have intensified since, with some countries at significantly greater risk. For example 34% of Filipino nurses passed the OET in 2005 compared to just 21% in 2010. By 2011, new standards meant 8% of nurses in all who would have passed the OET under previous requirements were deemed to have failed. Second, pre-migration qualification screening in the 1990s resulted in immediate recognition for 97% of ESB nurses compared to just 29% of NESB nurses. Third, while the introduction of competency-based assessment courses represented a very significant Australian qualifications recognition reform from 1989 (producing 90-95% pass rates in Victoria and 55-71% rates in NSW), funding for these courses was unstable and inadequate, with courses restricted to internationally educated nurses resident in Australia. 32
Finally, while both ESB and NESB nurses secured professional employment once registration was gained, significant and persistent labour market segmentation was evident for many NESB nurses, with East European and non-Commonwealth Asian nurses disproportionately concentrated in the geriatric care sector. A nominal regression analysis demonstrated East European and non-Commonwealth Asian nurses to be 840% more likely to be employed in nursing home work than ESB nurses – an industry in the process of being redefined as suitable for „foreign labour‟ (OR: 9.4; 95%Cl:2.9-30.2). No comparable disadvantage was found for any other ethnic group studied, even those with similarly basic qualifications. When work status was analysed by region of origin, NESB nurses proved significantly less likely than ESB nurses to have progressed beyond baseline registered nurse employment. Sixty-seven per cent of NESB females were employed as „just‟ RNs, compared to 56% of NESB males and ESB females, and a low 30% of the relatively elite ESB males ( 2=27.97, p=0.02). Though 16% of NESB males and 20% of NESB females in the research sample had found specialist or charge nurse positions, they had achieved minimal representation in higher managerial or nurse supervisor positions - despite the reasonable qualifications level and relative seniority of Commonwealth-Asian nurses (eg from Hong Kong or Singapore). Between 2007 and 2010 the Australian Nursing and Midwifery Council received 11,051 applications from nurse PA‟s seeking a GSM assessment. The principal source countries at this time were India (2,437), the UK (2,358), China (1,316), the Philippines (957) and Zimbabwe (471). As in Australia, migrant nurses were a highly feminised group (85% of applicants). Substantial numbers were deemed suitable for migration purposes (10,029). However just 16% secured full recognition while 75% were given modified approval (with pre-accreditation assessment/ training required on arrival in Australia). The remainder (9%) were deemed unsuitable or pending. No outcomes were provided by country of training, though these were sought for the Scoping Paper. Given the scale of recent flows, Australia urgently needs updated research on registration and employment outcomes associated with nurse migration. Dental Registration To secure registration to practice, international dental graduates (IDG‟s) are required to demonstrate their completion of a dental degree or diploma (at least 4 years full-time academic study at a recognised university), completion of pre-registration clinical experience, full registration in country of training or practice, and a certificate of good standing from the relevant registration authority. By 2006 however just 37% of IDG‟s secured dental employment in Australia in their first 5 years. Outcomes were poor for a range of birthplace groups - for instance just 5% of dentists from Central/South America securing dental employment, 7% from the Philippines, 21% from China, 23% from India (a rapidly growing source) and 35% from Sri Lanka/Bangladesh47. These outcomes, as we have seen, contrasted starkly with those for recent IDG‟s qualified in South Africa (89% employed as professional dentists), Malaysia (84% - many who had qualified in Australia), and the UK/ Ireland (82%). From 2000 to 2009 1,048 international dental graduates were deemed eligible for registration in Australia through the Australian Dental Council assessment pathway – an extraordinary contribution. According to the Australian Institute of Health and Welfare, this compared to around 35 applicants per year in the 1990s, rising to 158 in 200648. Demand for assessment had grown markedly in recent years. In 2000 for example just 105 IDG‟s took the Preliminary exam, with a 15% success rate. This compared to 608 in 2010 (27% passing). Clinical pass rates were higher that year, at 43%. Dental migrants‟ diversity, differential training systems, and levels of English represent major challenges, along with the resources required to deliver sufficient 33
Clinical exams in the context of rising dental migration. By 2011 the ADC was assessing candidates from 120 source countries, trained in over 400 dental schools, including multiple schools within a single university (for example in India). The impact of such demand is significant, in a context where IDG‟s are allowed unlimited attempts, two exams series are held per year over a six to seven day period, and 8-9 exam sessions are included in each. The ADC now reports significant pressure in securing sufficient examiners and clinical locations. Pharmacist Registration In 2009-10 the top countries of training for Stage 1 Australian Physiotherapy Council eligibility assessments were Egypt (38%), India (25%) the Philippines (10%), South Africa (6%) and Nigeria and Pakistan (3% each). Following passes a Competency Assessment of Overseas Pharmacists examination is administered for eligible overseas trained pharmacists four times a year, in London, Auckland and Australian capital cities. This includes the National Forensics, Ethics and Calculations Examination, which assesses candidates‟ capacity to apply their knowledge to an Australian context. The primary source countries for stage 11 assessment in 2009-10 were Egypt (52%), India (17%), Zimbabwe (4%), Pakistan, South Africa and Nigeria (3% each) 49. No data could be sourced by key variables such as country of training in terms of assessment outcomes. Physiotherapy Registration The scale of physiotherapy migration is modest to date - just 2,409 degree-qualified overseasborn physiotherapists resident in Australia by 2006, including 469 admitted the previous 5 years. An additional 394 „physiotherapists‟ arrived in this period holding diploma qualifications (unlikely to secure registration at the professional level). In consequence the Australian Physiotherapy Council assesses a modest number of applications, though demand is trending up (from 93 in 2007 to 134 in 2010). Between 2007 and 2010 a total of 546 applicants were approved, most notably for physiotherapists qualified in England (105) and India (51). No data were available to allow assessment of the characteristics of migrant physiotherapists unable to secure APC certification.
5.8 Bridging Interventions Assessment of the range, purpose, delivery mode, funding base and effectiveness of bridging interventions to assist migrant health professionals was beyond the scope of the present study. Such interventions can play a critical role for recent and medium term migrants who have been professionally displaced. Bridging courses take time however, and the cost can be high. Migrants located in regional/ remote sites report particular barriers to course access. Few options exist beyond nursing and medicine (despite important current initiatives in some allied health fields). By 2007, for example, Health Canada had allocated $C75 million to bridge up to 1,000 IMG‟s, 800 nurses and 500 other allied health professionals into the Canadian workforce, a process anticipated to take up to 5 years50. According to the Medical Council of New Zealand51, $NZ11.8 million was recently allocated to bridge 300 migrant doctors into full registration in a trial program. 1,221 applications were received (selection criteria including well recognized medical qualification, a certificate of good standing, a pass in the NZREX IELTS, and permanent resident status). The pilot course provided 4.5 months training in medical knowledge and skills, followed by 6 month supervised rotations in public hospitals, then candidature for the NZREX Clinical exam. 181 of the 300 selected candidates passed this exam, but some subsequently moved to Australia. Regrettably the high cost of bridging could not be sustained, despite strong advocacy 34
(eg from refugee doctors), in the light of New Zealand‟s modest overall IMG outcomes. By contrast Australia has achieved highly effective outcomes in relation to migrant nurse bridging programs – a Western Australian three month course transforming exam fail rates of around 90% in the 1980s to pass rates near 90% within a year, and competency-based courses in Victoria and NSW yielding highly efficient outcomes52. For migrant health professionals access to bridging training can be critically important, in particular for those admitted as dependents and through family or humanitarian categories, and/or those working on a conditional registration basis. This was strongly affirmed by the key informants interviewed, together with submissions to the 2011 House of Representatives Inquiry on Overseas Trained Doctors. Programs to date however have been under-resourced, underresearched and provided on an ad hoc basis – NESB migrants‟ pathway to full registration often taking years. While government loans are available under the federal Fee-Help system, just 144 students took health courses in 2009 (the proportion who were recent migrants remaining unclear)53.
5.9 International Students as a Health Workforce Resource Within this complex policy environment, as demonstrated earlier, international students emerge as an immediate health workforce resource. While the ethics of international student migration are a matter of debate, parents rather than source countries have resourced these students‟ education. From an ethical perspective their recruitment can seem less problematic than the OECD migration norm - selection of mature-age professionals fully trained by their source countries. The great majority of former students are exempt from English language testing. They hold Australian qualifications. As demonstrated by analysis of the Graduate Destination Survey for 2006 to 2010, following graduation they secure employment and salary rates far exceeding those of most skilled, family and humanitarian category migrants (within 4 months). As noted 98.99% of international medical students still resident in Australia were employed full-time in medicine in 2010 compared 99.7% of domestic graduates; 93.8% of dental students (compared with 93.6%); 69.6% of nursing students (compared to 93.4%), with a further 20.8% working in nursing part-time; and 69.2% of physiotherapy students (compared to 91.3%), with a further 19.2% working in physiotherapy part-time. Canada, New Zealand, the US and the UK (among other countries such as Japan) are currently intensifying their efforts to attract and retain international students as a workforce resource54. In terms of medicine however, it is vital for international students to secure Australian internship places - a mandatory requirement for eligibility for skilled migration (noting 66-70% currently wish to stay). Within this context, health workforce planners must address the growing competition between students and migrants to secure clinical training places. This is a threat to permanent resident AMC pathway doctors (at risk of end-point displacement following years of study). It also risks curbing medical student migration. The issue is of growing concern, with both social justice and economic efficiency dimensions.
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6. Emigration Versus Retention of Health Professionals 6.1 Domestic Compared to Migrant Health Professional Emigration Beyond the challenge of attracting, registering and employing skilled migrants, there is the issue of national and regional retention. Australia lost 15,317 medical and allied health professionals from 2004-05 to 2009-10. In 2009-10 2,875 health professionals emigrated permanently from Australia, compared to 2,203 in 2004-05. The majority were of prime workforce age. Females dominated - a striking 72% of the total, reflecting the mobility of domestic and international nurses. Forty-eight percent were Australia-born, followed by health professionals from New Zealand (14%), the UK (11%), Hong Kong SAR (3%), China (4%), Ireland, Malaysia, the USA, Philippines, Canada and South Africa (1% each). Health professionals‟ out-emigration was significant in the following fields: Medicine: 540 permanent departures in 2009-10 (compared to 424 in 2004-05) Nursing: 1,274 permanent departures in 2009-10 (compared to 988 in 2004-05) Dentistry: 53 permanent departures in 2009-10 (compared to 70 in 2004-05) Physiotherapy: 174 permanent departures in 2009-10 (compared to 103 in 2004-05) Pharmacy: 123 permanent departures in 2009-10 (compared to 81 in 2004-05) Other allied health professions: 711 permanent departures in 2009-10 (compared to 537 in 2004-05) Substantial numbers of migrants had first reached Australia on a temporary resident basis – a mode with clear risks to their long-term retention. For example in 2009-10 340 overseas-born doctors permanently departed, compared to 195 who were Australia-born. Thirty-nine migrant dentists left, compared with 12 born in Australia. The majority of health professionals left New South Wales (991), followed by Victoria (660), Queensland (640), Western Australia (366) and South Australia (158). Such trends are not surprising in a global age, but they confirm the need for satisfactory and constant replacement – despite the threat of over-supply advised in a recent report55. Within this context, utilising the skills of the health professionals Australia imports represents a critical issue. In its strategy for securing „the “right” numbers in the “right” place at the “right” time‟, the National Health Workforce Strategic Framework placed minimal emphasis on the scale and type of out-migration, or measures to prevent this. This was also the case with the 2009 National Health Workforce Taskforce report, and a range of occupation-specific Australian Institute of Health and Welfare studies56. Yet emigration arguably represents a critical workforce issue alongside demographic change, domestic training, shifts in professional and organisational boundaries, and the introduction of new technologies to boost health care57. There is limited research to date on this issue. Many of these health professionals first arrived on a temporary basis. Global competition to recruit and retain the „best‟ sources of migrant health professionals is rising, with attractive options developing in OECD sites, in addition to the Gulf States, Africa and Asia. (See New Zealand and Canadian case studies in Section 8.)
6.2 Regional Retention In addition to the scale of out-migration, Australia experiences a constant „churn‟ of migrant health professionals relocating from rural/ remote and public sector positions to urban and/or private practice sites. This pattern is unlikely to stop, necessitating constant „back-filling‟ while 36
undermining stable distribution and workforce supply. For this reason empirically sound strategies to maximize regional retention are essential. Regional retention represents a critical issue, in the context of growing state/ territory sponsorship as noted in Section 1. It is important to recognise that hyper-mobility is associated with many migrant health professionals. A study commissioned by the Rural Workforce Agency, Victoria in 2003 found 66% of all respondents had made 5 major geographical moves prior to their current position (to one or more countries and then additionally within Australia). Overall, the following factors appeared critical in determining retention of IMG‟s in rural general practice employment: Family needs were paramount - with access to good education for children cited by 97% of all IMG respondents as fundamental to determining long-term location, followed by access to a good/well paid medical job (ranked as very important or important by 95%), a higher salary (89%), improved medical facilities (88%), and better collegial support (87%). Access to examination preparation training courses was considered to be very important or important in terms of long-term retention by 77% of all IMG‟s, an issue closely followed by access to better medical training (76%), shorter working hours (76%), provision of a formal contract (75%), location near family/friends (73%), metropolitan location (70%), better supervision/mentoring (62%), and access to religious facilities (62%). Proximity to ethnic community was cited by just 35% of IMG‟s – though this was perceived as important by many spouses, who did not have the distraction and satisfactions of GP work58. The retention of migrant health professionals in undersupplied sites is thus challenging. While willing to serve in public sector, regional and/or remote locations for periods of time, in particular when constrained by the terms of the 457 temporary visa, their aspirations are comparable to those determining the practice choices of mainstream Australians. Within this context there is a perceived need for basic modelling on health workforce supply to inform realistic planning. According to one key informant: One of the things we‘re trying to do is work with communities round new models of access to primary care services, to give them hope that they don‘t have to take their family and leave town… But also to realistically find some models that will give services to the community, whether it‘s fly in-fly out or drive in-drive out… (There) has been a glaring gap in that there is no rigorous primary workforce modelling service, to tell us how many GP‘s or practice nurses you should have for primary health care. We need that modelling now, so we can put some rigour into the rural communities – define who we need, how we‘re going to get them and how we can fund that! I feel we‘re kind of wandering around in the dark, and the best we have to offer is hope. There is also a need to feed data related to migrant health professionals into this modelling process, including estimates of their early productivity, likely registration status, hours worked and length of retention for different cohorts.
6.3 Impact of New Governance Strategies Following the major COAG reforms, it is finally important to note there is a perceived risk of Australia discouraging and/or losing health migrants. The recent period has seen the introduction of nationally consistent quality assurance mechanisms – an important policy measure. According
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to key informants however, the process has been associated with excessive red tape, severe processing delays, and heightened assessment requirements – one noting in relation to medicine: (The current Senate enquiry into IMG‘s registration processes highlights the common issues that each state is facing) – issues round bureaucracy gone crazy and no one agency taking responsibility for the pathways for the IMG coming in. They get bounced between the AMC, AHPRA, back to AMC, specialist colleges get involved, and everyone‘s useless! (Individual agencies have got) no sense of responsibility or urgency – that it‘s a community that needs a doctor, which is why we‘re all working hard here! Everyone‘s got the same issues around the processes. Select states are reportedly at disproportionate risk, given the growing attraction of global competitors to migrant health professionals.
7. Future Research Priorities In the period ahead, on the basis of the Scoping Paper findings, it is recommended that in-depth research be conducted on the following priority topics: 1. The growing scale of allied health workforce migration to Australia – defining the characteristics of migrant intakes, pathways to professional registration, employment distribution and outcomes. 2. A definitive analysis of nurse migration and outcomes given the numerical dominance of this field - assessing recruitment strategies, barriers to labour market participation by cohort, factors influencing employment and retention outcomes. 3. The impact of English language assessment – a critical review of the instruments used, their fitness for purpose, and the rationale for requiring all four sub-tests to be passed at a single sitting, given the negative impact of this for select groups on registration and employment to date. 4. The role of bridging programs in facilitating access to employment – a detailed audit of the range of interventions available for migrant health professionals, their mode of operation, costing model, level of uptake (by field and across Australia), and degree of effectiveness in enhancing labour market integration outcomes. 5. The impact of new medical registration pathways on access to practice – comparison of the Competent Authority, Workplace-Based Assessment and Australian Medical Council pathways, including their impact on global recruitment, and potential application to the allied health professions. 6. Factors influencing international student recruitment and transition to practice in Australia – in medicine and allied health fields, within an increasingly competitive global and national environment. 7. Policy levers to maximise migrants’ distribution and retention – assessment of the determinants of public sector and/or regional employment by key field, including strategies likely to maximise employment satisfaction/ retention (noting minimal examination of this in relation allied health fields to date).
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8. Health workforce emigration – including definition of the „push‟/ „pull‟ factors influencing domestic graduates compared to GSM migrants, 457 visa migrants, migrants selected through other immigration categories, and former international students, supported by analysis of strategies likely to enhance different cohorts‟ retention. 9. Factors in immigrant source countries with a potential to impact on future workforce supply – critical analysis of trends and immigration „drivers‟ in the UK, Ireland, New Zealand, South Africa, India, China, Malaysia and the Philippines. 10. Strategies in key competitor countries to recruit and retain migrant health professionals – detailed audit of policies operating in the UK, Ireland, New Zealand, Canada, and the USA, including selection priorities, permanent compared to temporary resident pathways, geographic distribution, language testing and vocational registration requirements, and quality of employment outcomes. On the basis of the research evidence, the policy imperative for Australia is to prioritise which migrant health professional cohorts it should seek to recruit and retain in the future, including the policy levers it should use to achieve this. Prior to reaching the goal of domestic self-sufficiency by 2025, Australia has the choice of: 1. New Zealand health professionals – who secure identical outcomes to domestic graduates. 2. Temporary 457 visa health professionals - an immediately effective resource, with a capacity to be tied to specific locations for up to 4 years (noting however many lack full registration status and will choose not to stay). 3. Permanent GSM migrants - professionals who secure positive early labour market outcomes, like 457 visa migrants, and have made a long-term commitment to settle in Australia. 4. Former international students qualified with Australian degrees - a highly advantaged and acculturated cohort, facing minimal employment barriers. 5. Permanent family and humanitarian migrants - characterized by a commitment to Australia, but at risk of extended professional displacement and significant need for support.
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Section 1: Australia’s Skilled Migration Policy Context 1.1 Permanent Skilled Migration to Australia in the Recent Decade Introduction Effective governance of health workforce migration is challenging, in a context where Federal and state/ territory governments must: Compete in the global recruitment of skills; Define the migrant health professionals most likely to secure vocational registration; Determine which workers will have a capacity to integrate at speed; Ensure migrants‟ dispersal post-arrival - using domestic policy levers to address workforce maldistribution as well as under-supply; and Enhance national as well as regional retention, in a context where hyper-mobility and on-migration have become global norms. It is important to acknowledge at the start of this study that the costs of health workforce recruitment are high. For example the 2011 Rural Workforce Agency, Victoria (RWAV) submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors estimated in relation to medicine alone these included: $1.6 billion for Health Workforce Australia (HWA); $20 million for the Rural and Remote General Practice Program (Workforce Agencies and RWAV); and $4 million for additional support and the international recruitment scheme – these figures excluding further investment in relocation, rural and remote incentives through Medicare59. Within this policy context it is vital for Australian governments and employers to import skills which can be used, noting that vast numbers of migrants who move globally experience professional displacement. To set the scene, Australia‟s skilled migration policy is first described (Section 1), followed by analysis of recent health migration flows and employment outcomes. The Study Focus: Overseas-Trained Recent Arrivals and Former International Students Five major sources of health workforce migration are the focus throughout this study: 1. New Zealand health professionals – Characterised by free entry to Australia and mutual recognition of qualifications under the terms of the Trans-Tasman Agreement; 2. Permanent skilled migrants - Selected as primary applicants on the basis of their human capital attributes through Australia‟s General Skilled Migration Program (the GSM); 3. Temporary labour migrants - Sponsored by employers through Australia‟s 457 long-stay visa program to fill specific positions; 4. The dependents of skilled migrants, plus family and humanitarian category arrivals – Selected in non-labour categories, unfiltered in advance for human capital attributes; and 5. Former international students - Qualified in Australian medical or allied health degrees, who convert status to remain through a process termed „two-step migration‟. 40
Health Professionals Migrating as Children Throughout the following analysis, emphasis is placed on recent arrivals who have qualified overseas (the sole exception being international students). It is important to acknowledge that vast numbers of Australian medical and allied health professionals are also first generation migrants, who arrived with their families as children. By 2006 Australia included the world‟s highest percentage of foreign-born (24%), followed by New Zealand (23%), Canada (20%), and the US (11%). The children of recent migrants have disproportionately qualified in medicine and dentistry. By the mid 1990s, for example, 40% of permanent resident students in Australian medical courses were first generation Australians. A striking 24% were Asia-born (six times the Asia-born proportion in the overall population) with 15% from South-East Asia, 7% from North-East Asia and 3% from South Asia, compared to just 7% derived in total from Europe, the UK/Ireland, and the former USSR/Baltic States. (See Table 1.) Analysing the changing demography of Australian medical schools as early as 1994, one analyst noted that: In general, immigrant groups are very well represented in medical studies. The participation rate for all overseas-born Australians who are permanent residents is more than three times that of the Australia-born… (R)esidents from (Malaysia, Vietnam and Hong Kong) are five to ten times more likely to be studying medicine than the Australiaborn (all origins). The Vietnamese achievement is particularly noteworthy, given that the community from which these students are drawn is one of the most depressed in Australia, at least as judged by the level of unemployment and the extent of adult dependence on low-paid unskilled work60. Table 1: Participation Rates of Permanent Resident Undergraduate Medical Students in Australia aged 15 to 24 by Select Country of Birth: 1993 Country of Birth Malaysia Hong Kong Vietnam UK & Ireland Greece Lebanon Philippines Australia All overseas born
Base Population (15-24 years) 22,672 20,487 33,736 76,402 3,844 11,164 11,761 2,336,377 409,781
No. of Medical Students 478 295 347 307 7 22 4,143 4,143 2,787
*Participation Rate 21.1% 14.4% 10.2% 4.0% 1.8% 2.0% 1.8% 1.8% 6.8%
Source: Betts, C (1994), „Medical students and the changing make up of the Australian medical workforce‟, People and Place 2 (2): 26. Participation rate* is the number of students per 1000 base population, based on Australian Bureau of Statistics and Department of Employment Education and Training data.
These Asia-born medical student enrolments represent an outstanding example of the academic success achieved by recent migrant and refugee groups – one of the major achievements of Australia‟s post-war migration program. Comparable trends are evident in dentistry Vietnamese-born students by the mid 1990s securing seven times the normal level of course representation61. These citizens/ permanent residents who reach Australia as children and qualify locally face no labour market barriers (demonstrated by successive Census analyses). They are 41
not the subject of the current study, which focuses on overseas-trained health professionals in addition to former international students. Growth in Skilled Migration and Diversification of Source Countries The recent decade has coincided with an extraordinary level of skilled migration to Australia, across all immigration categories62. In 2009 the population stood at 21,875,000 people, following the largest growth in 20 years (a net annual gain of 443,100 people). Immigration was the primary source, despite domestic fertility rates rising to 2%, with immigrants selected through the skilled, family, and humanitarian categories. Between 2001 and 2006, 596,201 new migrants with postschool qualifications arrived, compared with 217,477 from 1996-200063. Thirty-six per cent were degree-qualified (both males and females), including a third holding Masters or Doctoral degrees. (See Table 2.) Table 2: Level of Australian and Overseas Born Persons Holding Post-School Qualifications (2006), Migrants Grouped by Time of Arrival in Australia, percentages
Grad Diploma/ Grad Certificate
Batchelor
Advanced Diploma/ Diploma
Total (a)
Number (a)
Certificate/ No PostSchool Qualifications
Qualifications
Gender
Master/ Postgraduate
Arrival time
Doctoral
Birthplace
Male Female All
0.7 0.4 0.6
2.5 2.1 2.3
1.2 2.0 1.6
11.6 14.3 12.9
6.4 8.8 7.6
77.6 72.4 75.0
100.0 100.0 100.0
6591962 6681746 13273708
Pre-1996
Male Female All
1.4 0.7 1.0
3.7 2.7 3.2
1.4 2.0 1.7
14.9 16.0 15.5
8.2 10.0 9.1
70.4 68.5 69.5
100.0 99.9 100.0
1091399 1133532 2224931
1996-2000
Male Female All
1.9 0.9 1.4
8.2 6.0 7.1
1.3 1.6 1.4
20.4 21.6 21.1
8.8 11.2 10.1
59.4 58.6 59.0
100.0 99.9 100.1
176541 192185 217477
2001-2006
Male Female All
1.5 0.8 1.1
10.1 7.9 9.0
1.1 1.3 1.2
23.4 25.5 24.5
9.3 11.2 10.3
54.6 53.4 54.0
100.0 100.1 100.1
290732 305469 596201
Male 1.5 5.4 1.3 17.1 Female 0.7 4.1 1.8 18.5 All 1.1 4.7 1.6 17.8 Source: 2006 Census (Australia), unpublished data Notes: Excludes those for whom birthplace unknown. a = Due to missing data, imputation and aggregation, numbers may not add up to 100% or exact total.
8.5 10.4 9.5
66.2 64.5 65.4
100.0 100.0 100.1
1558672 1631186 3189858
Australia
Overseas
S/Total arrivals
Within the past decade the impact of migration on key Australian professions has become profound. By 2006 57% of all degree-qualified information technology professionals were overseas born, along with 53% of dentists, 52% of engineers, 45% of doctors, 44% of accountants and 24% of nurses. Disproportionate numbers had reached Australia in the previous 5 years, including 36% of Australia‟s total professional IT workforce, 32% of accountants, 28% of engineers, and 25% of migrants holding medical qualifications. (See Table 3.) It should be noted that public estimates of the proportion of migrant health professionals in the Australian workforce and overseas-trained are substantially lower (generally around 25% for medicine and 12% for nursing – for example as assessed by the Productivity Commission in 2005
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and by the Australian Institute of Health and Welfare in 2004 and 201064). By definition not all overseas-born doctors and nurses are working at a given point in time. There are also significant numbers of recent arrivals, retirees, and those „not in the labour force‟ for family and/or preaccreditation reasons.
Overseas-born By year of arrival 2001-2006
Degree/Higher degree Information technology Engineering Medicine Nursing Accounting/Business/Commerce Teaching Law Other S/Total
42.8 48.4 54.6 75.0 58.8 75.3 74.4 67.0 64.9
57.2 51.6 45.4 25.0 41.2 24.7 25.6 33.0 35.1
43.9 57.6 62.6 72.6 52.3 69.5 68.6 61.1 59.1
20.5 14.1 12.8 9.2 16.2 11.0 11.0 13.6 14.2
35.6 28.3 24.6 18.2 31.6 19.4 20.4 25.4 26.7
100.0 100.0 100.0 100.0 100.1 99.9 100.0 100.1 100.0
116,523 159,940 72,068 162,372 456,062 443,231 84,515 820,210 2,314,921
Diploma/Advanced Diploma/Certificate IV Information technology Engineering Medicine Nursing Accounting/Business/Commerce Teaching Law Other S/Total
66.4 72.0 62.8 73.7 71.6 75.0 83.0 71.5 71.5
33.6 28.0 37.2 26.3 28.4 26.0 17.0 28.5 28.5
60.4 77.4 61.6 73.5 67.9 72.0 75.5 75.0 74.4
15.5 8.3 12.7 8.8 12.0 10.9 10.0 9.7 9.9
24.1 14.3 25.6 17.7 20.1 17.2 14.5 15.3 15.7
100.0 100.0 99.9 100.0 100.0 100.1 100.0 100.0 100.0
102,240 365,195 17,138 160,148 437,792 173,837 32,981 9,669,456 10,958,787
All overseasborn
Total (a)
1996-2000
Australia -born
Pre-1996
Qualification level and field
Number (a)
Table 3: Australian Professional Workforce (2006) by Qualification Level and Field, Birthplace and Year of Arrival, percentages
Source: 2006 Census (Australia), unpublished data accessed 2008, ABS
Notes: Excludes those for whom birthplace or year of arrival is unknown. a = Due to missing data, imputation and aggregation, numbers may not add up to 100%.
Within the recent period, as demonstrated below, immigrant source countries have also dramatically diversified. By June 2011 Australia included over 2 million Asia-born immigrants – a number set to overtake the Europe-born population „for the first time in history‟. According to the Australian Bureau of Statistics, from 2005 to 2010 Australia‟s Asia-born population close to doubled (rising from 1.03 million to 2.01 million people). It constituted a third of all population growth at this time. For example the number of China-born residents in Australia surged from 148,000 to 380,000, while the India-born population trebled from 96,000 to 340,000. Middle Eastern migration rose markedly, driven in part by refugee flows from Afghanistan and Iraq (including many arrivals who were medically qualified)65. The Scale of New Zealand Migration While New Zealand arrivals are not counted as skilled migrants to Australia, given their entitlement to free movement through the Trans-Tasman agreement, it is important to affirm at the start of this study that their contribution is large.
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In 2008-09 25,578 New Zealanders reached Australia as settlers, compared to 18,677 in 1998-99, making a total of 221,643 arrivals across the decade (all fields). New Zealanders represent a major human capital resource for Australia, in a context where 544,000 were resident by 2010 and just 69,884 had permanently departed in the previous 10 years66. As demonstrated in Section 2 of this study, large numbers are qualified in the health professions – 2001-06 arrivals including 1,247 New Zealand nurses/midwives, 368 qualified in other allied health fields, 240 in medicine and 44 in dentistry67. Australia‘s Permanent Skilled Migration Program New Zealand flows aside, in recent years the majority of degree-qualified migrants selected by Australia have been admitted through the General Skilled Migration Category. Substantial numbers also arrived as family category migrants and as refugees. Between 2004-05 and 200809, 358,151 permanent GSM migrants were selected, including 72,172 people in 2008-09 (counting dependents). Skilled migration constituted two-thirds of Australia‟s immigration program at this time. In 2009-10 a target of 182,450 permanent arrivals was set, split between the following categories68: Skilled – 108,100 (59%) Family – 60,300 (33%) Humanitarian – 13,750 (8%) For 2010-11 Australia‟s permanent migration target was set at 190,300 people, with 113,850 GSM migrants plus a skilled migration category extension. (See Table 4.) Table 4: Permanent Immigration Intakes to Australia by Major Category Program Numbers by Stream Family Skilled Special Eligibility Humanitarian
1996-97
1998-99
2001-02
2006-07
2007-08
2008-09
2009-10
44,580 27,550 1,730 11,900
32,040 35,000 890 11,356
38,090 53,520 1,480 12,349
50,080 97,920 200 13,017
49,870 108,500 220 13,000
56,500 115,000 300 13,500
60,300 108,100 300 13,750
2010-11 Plan 54,550 113,850 300 13,750
Source: Adapted from data in Department of Immigration and Citizenship, “Reform of Australia‟s Skilled Migration Program and Key Inflows: We‟ve Checked Our Policy Settings – Now What?”, May-June 2010, Canberra; and Koleth, E (2011), „Budget 2011-11: Immigration‟, Parliament of Australia, http://www.aph.gov.au/library/pubs/rp/BudgetReview2010-11/ImmigrationPrograms.htm, accessed 21 August 2011.
Data Challenges A number of methodological issues should be noted in relation to the research findings: Highly variable levels of data are sought/ kept in relation to the different immigration categories. The greatest level of information (including occupational and demographic characteristics) is available for primary applicants selected in the General Skilled Migration category - migrants filtered by DIAC on the basis of their employment attributes. Far more limited data are available for GSM dependents - despite many partners having comparable education and employment skills, and an intention to work. Modest data are available for 457 visa temporary health professionals (including age and gender, and for the 2004-05 year of arrival). Very little is known of their partners, despite these being accorded the right to work. 44
Least data are available for family and in particular humanitarian category entrants, approved for entry to Australia on the basis of relationship or perceived need. Given this, the most comprehensive source of attributes and occupational data for migrant health professionals is the Australian Census – last collected by the Australian Bureau of Statistics (ABS) in 2006, and capturing all permanent as well as temporary residents. Multiple additional databases were sourced (some not previously analysed for health workforce planning purposes). Indeed, a comprehensive analysis of health workforce immigration to Australia is long overdue. As noted in a recent assessment of health workforce supply by the Australian Institute of Health and Welfare: New entrants to the workforce are mainly from the education system and skilled immigration. Departures from the workforce include migration, resignations, retirements and death. Not all these elements of workforce supply can be accurately measured. For example current health workforce migration data are not considered to be of sufficient quality to provide a reasonable measure of this component69. The aim of the present study is to provide a more definitive level of analysis on immigration and emigration than attempted to date, assessing the major recent sources. Skilled Migrant Characteristics – Gender, Qualifications, Age Since 2001 skilled category migrants to Australia have been eligible to apply both on and offshore, on a sponsored or on an „Independent‟ points-tested basis70. Between 2004-05 and 2008-09 246,405 Independent primary applicants71 with family arrived - the dominant entry pathway for the past 3 decades72. Employer, state/territory and family linked skilled arrivals were the source of an additional 111,746 GSM migrants in these years, including migrants selected through a range of sponsored and/or regional sub-categories admitting many migrant health professionals73: Skilled Australian Linked/Australian Sponsored - 36,707 Skilled Australian Linked/Regional - 34,050 State/Territory Nominated Independent - 16,264 Skilled Independent Regional - 14,554 Additional sponsorship schemes - Around 10,000 From 2004-05 to 2008-09 two-thirds of GSM primary applicants were male (63%) - the great majority of prime workforce age, with 18% aged 15-24, 57% 25-34 and 23% 35-44 years (female PA‟s being slightly younger). Interestingly, Australia has experienced declining rather than growing female GSM participation in recent years – women constituting a third of PA‟s in 200809 compared to 39% five years earlier. Near gender equity prevailed however in the GSM program overall, with women contributing 46% of 2004-05 to 2008-09 arrivals once accompanying family members were factored into the total. Skilled migration primary applicants were qualified at the following levels in these 5 years: Professionals - 124,915 Associate professionals - 8,480 Managers/administrators - 5,964 Trades - 30,375 Clerical workers - 3,887 Low skilled - 14,367 45
The top 5 professions for primary applicants to Australia at this time were accounting (32% or 40,054 of skilled arrivals), computing (23% or 28,858), architecture/building (9%), engineering (9%) and nursing (5%). As noted above, skilled category family members also significantly boosted the scale of arrivals in select occupations. For example from 2004-05 to 2008-09 1,489 medical practitioners migrated to Australia as skilled PA‟s – a number rising to 2,593 once GSM spouses are factored in. Spouse field by contrast made minimal difference to the scale of arrivals in nursing (a 7,676 total compared to 6,400 primary applicants). It is important to affirm that health workforce migration to Australia intensified rather than reduced in 2009-10 – the latest General Skilled Migration data showing the following arrivals by field: Nursing: 1,700 GSM PA‟s (compared to 1,360 in 2008-09) Medicine: 1,070 (compared to 450) Other health professionals: 1,170 (compared to 1,070) Total: 3,940 (compared to 2,870) – a 37% increase over 2008-09 Skilled Migrant Characteristics – Source Countries Beyond the recent scale of flows, a critical issue to note at the start of this study is the diversity of skilled migrants‟ source countries – one with significant implications for health professionals‟ employment and practice outcomes. Australia currently selects few primary applicants from the major English speaking background (ESB) countries, typically defined as the UK, Ireland, the USA, Canada, South Africa, New Zealand and Australia. Between 2004-05 and 2008-09 eight of the top 10 GSM source countries were located in Asia, as follows: 1. India (21% or 39,671 migrants admitted) 2. China (18% or 33,309) 3. UK (14%) 4. Malaysia (6%) 5. Indonesia (4%) 6. Sri Lanka (3%) 7. Republic of Korea (3%) 8. South Africa (3%) 9. Hong Kong SAR (3%) 10. Singapore (3%) Only three English speaking background nations featured in Australia‟s GSM top 20, at a time when the UK, South Africa and Ireland contributed 25,710, 4,883 and 2,044 of skilled PA‟s each (just 17% of the total, compared to 46% in New Zealand)74. Fourteen of Australia‟s top 20 source countries were in Asia. No European countries featured beyond the UK and Ireland. Zimbabwe was the sole additional African country, and Fiji the primary Pacific source - each contributing just 1% of the GSM total. Once dependents are factored in, between 2004-05 and 2008-09 a total of 72,841 UK migrants reached Australia75, followed by 68,210 from India, 46,504 from China, 17,321 from Malaysia, and 14,695 from South Africa. The Scale and Source of General Skilled Migration Health Worker Migration The level of diversity is less for health workforce migration. The top 10 source countries in 200910 for GSM health-qualified arrivals were: 1. UK: 960 or 24% (compared to 800 in 2008-09)
46
2. 3. 4. 5. 6. 7. 8. 9. 10.
India: 610 or 15% (compared to 350) Malaysia: 380 or 10% (compared to 320) China: 360 or 9% (compared to 200) Egypt: 190 or 5% (compared to 90) South Africa: 130 or 3% (compared to 110) Philippines: 130 or 3% (compared to 120) Republic of Korea: 110 or 3% (compared to 90) Singapore: 100 or 2% (compared to 60) Ireland: 90 or 2% (compared to 70)
Forty-three per cent of GSM health migrants were derived from the major English speaking background countries, in marked contrast to the 17% program norm. Reflecting the scale of nurse migration, most of those selected for admission in 2009-10 were female (63% of the total). The majority were of prime workforce age: 34% aged 25-29 years, 27% aged 30-34, and 16% aged 30-39, while 8% were new graduates aged 20-24 years. 1.2 Temporary Skilled Migration and Employer/Regional Sponsorship Global Trends in Temporary Labour Migration These permanent skilled migration flows are highly significant. To set the scene in relation to health workforce migration however, it is important to define the growth of temporary labour migration to Australia - a rapidly escalating trend, particularly in the health professions. Between 2003 and 2004 the number of temporary workers resident in OECD nations increased by 7% (around 1.5 million people)76. Sponsored labour migration has become highly attractive to governments and employers - by definition delivering strong and immediate employment outcomes, with workers coming to pre-arranged jobs. According to a recent global analysis, It has been suggested that the temporary movement of skilled labour reflects ―the reality of today‘s global marketplace‖77. The structure of business, particularly the process of internationalization by large employers, is leading to increasing international mobility among highly skilled employees of these companies to meet client needs, provide input into project teams, and aid in professional development… Developed countries competing to attract skilled migrants have simplified and streamlined visa procedures for their temporary entry. Countries such as Germany, the United Kingdom, and the United States of America now have visa programs specific for the temporary entry of highly skilled labour. The acceleration of regional integration during the 1990s has also had a profound bearing on migration policies. Some regional free trade areas including NAFTA and the EU have removed some of the previous restrictions on the movement of labour. Regional and global trade regimes are likely to become more important vehicles for managing the mobility of skilled migrants78. By 2009 the number of temporary foreign workers admitted to Canada exceeded the number of permanent skilled immigrants (178,478 compared to 153,498)79. Research suggests such temporary labour entrants experience few of the employment barriers characteristic of government-selected economic category immigrants – Australia‟s 2006 skilled migration review finding that 99% of sponsored migrants were employed within 6 months, compared to 83% of points-tested Independent applicants. By definition employers pick skilled migrants with the attributes they seek - only sponsoring someone „if that person is believed to have the necessary education and work experience to be successful in the job‟80.
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The Recent Scale of Temporary Labour Migration – 457 Visa From 2004-05 to 2008-09 most Australian occupations were characterised by major temporary resident (TR) as well as permanent flows, in a context where what might be termed the „privatisation‟ of skilled migration has rapidly advanced. In Australia 418,940 arrivals were admitted in these years through the 457 visa long-stay business category, when the economic cycle was strong and the mining boom was fuelling demand for immediate labour81. This form of admission was highly relevant to the health professions. Annual numbers surged from 48,610 people in 2004-05 including dependents to 110,570 arrivals in 2007-08, moderating to 101,280 in 2008-09 during threatened recession. The category is uncapped, and health/ community services was the dominant sector. (See Table 5.) Table 5: Australian Employer Sponsorship of 457 Visa Long-Stay Workers by Sector (2006-07 to 2007-08) Industry Sector (457 Visa Sponsorship) Health/ community services Property/ business services Construction Manufacturing Communication services Mining Accommodation/ hospitality Finance/ insurance Education Retail trade
Employer-Sponsored Arrivals June 2007-June 2008 9,090 6,020 5,690 5,480 5,200 4,890 3,210 3,150 2,540 1,940
Growth Trend Compared to Arrivals 2006-07 +21% +33% +36% +26% +10% +36% +22% +48% +27% +58%
Source: Adapted from „Skill Migrant Visas Up by 24 Per Cent‟, P Maley, Australian, 23 July 2008, p 5.
‗Areas of Need‘ and Limited Registration By September 2009, according to the Department of Immigration and Citizenship, 70% of Australia‟s labour migrants were employer-sponsored, entering via the temporary as well as permanent skilled migration streams82. It is important to note in relation to this that temporary resident migrants can secure employment in Australia on a conditional or limited registration basis. In select professions, such as medicine, employer-sponsored workers can by-pass full assessment - proceeding immediately to sponsored Australian positions on a conditional registration basis. An identical trend prevails in Canada. As defined in a recent Department of Immigration and Citizenship report, The person identified to fill a nominated vacancy… must satisfy the department that they have skills which match those required for the vacancy for which they have been nominated… A skill assessment of the visa applicant is not generally required (unless there are doubts about his/her capacity to fill the position). Where Australian registration or licensing is required to undertake the nominated position, applicants may be asked to provide evidence that they are eligible for the relevant registration or licence. Medical practitioners are required to provide evidence of registration to practise in the state or territory in which they will be working83. Temporary migration is attractive to both governments and Australian employers, given the category‟s potential to proscribe migrants‟ location as a condition of visa entry (eg to work in
48
„areas of need‟). This option is also appealing to migrants, for example newly qualified British „backpacker doctors‟ who seek „adventure medicine‟ in Australia for a period of two years. International medical graduates (IMG‟s) accepting such positions are permitted to work under supervision for up to 4 years, without compulsion to secure full accreditation84. It should be noted however that the 2011 House of Representatives Inquiry into the Registration Processes and Support for Overseas Trained Doctors highlighted systemic problems related to the 457 visa and GSM programs, including a litany of concerns related to red tape, plus IMGs‟ experience of inequitable or prejudicial treatment (important issues that were beyond the brief of the present study)85. For example one Bulgarian IMG stated: I have been working in Australia for 11 years. I have two children born in Australia. I have no status in the country. I have no Medicare access. Since my wife is a NZ citizen and qualified for Medicare benefits I have to pay Medicare Levy and surcharge without having access to Medicare benefits. Since I don‘t have access to Medicare I pay private Health cover as a visitor… after 11 years in the country (Submission No. 0586). Doctors in submissions to this and many other enquiries have described comparable exploitation in their initial work. A South Asian temporary resident doctor recalled some years back: I remember after two days of transport, I landed in (a Queensland regional centre). I started the Tuesday in (a small outback town). The person that relieved already left on the Sunday because she had other work to do, so the hospital didn‘t have anybody for the Monday. On the Tuesday I had to start the practice and I had absolutely no idea of Medicare, how it worked. I asked the secretary. What I‘m saying is that in Australia‘s rural areas it can be very tough. In fact you must remember that I was in charge of a hospital by myself. I was the only doctor in that hospital of 55 beds. I was on call for three weeks non-stop. You know it would have been better if you prepared a chap better because then he would be happier and feel more secure and your population will then have a good doctor looking after them. And of course that is not a family life to be on call every night for three weeks and then have three days off. It‘s just not, you can give me all the petrol and money in the world but it gets on top of you. So that‘s why we left Queensland. While I was in Queensland the Director of Medical Services of (a regional town) came to me and he said, ―Oh, we definitely need doctors down in Victoria. Why don‘t you come and work for us?‖ I said, ―All right.‖ So then I flew down here and I was interviewed. I have now worked in two rural towns in Victoria87. Such issues were powerfully raised by Victorian, NSW and Western Australian key informants consulted in the course of the current study. The Scale of Temporary Health Worker Migration From 2004-05 to 2008-09 58% of Australia‟s 457 visa category were employed in a professional occupation pre-migration (128,520 arrivals), compared to 66% of GSM arrivals. Employers‟ preferred occupations for temporary workers varied markedly from those in the permanent program. Registered nurses were the primary group imported (25% or 7,580 people), followed by computing (13%), business professionals (10%), engineers (10%), and sales and marketing professionals (8%). Few accountants were sought, at a time when the Australian market was seriously oversupplied. Mechanical/fabrication engineering trades ranked sixth overall, followed by medical practitioners, science professionals, and teachers and lecturers (including those qualified in medical and allied health fields).
49
Growth by occupational sector was particularly dynamic from 2006-07 to 2007-08, at the height of Australia‟s mining boom. As we have seen, health and community services dominated (a 21% rise within a year) followed by property and construction (+33% growth). Please note that the age of 457 visa arrivals in Australia was more diverse than for the GSM program, reflecting larger family units. A slightly higher proportion were male than female. Sponsored workers could also arrive at speed: just 21 days required for the Department of Immigration and Citizenship to approve the entry of temporary sponsored professionals4. As early as 1999 the Australian Medical Workforce Advisory Committee published a report on temporary resident doctors in Australia88. By 2009-10 6,020 migrant health professionals were sponsored by Australian employers on the 457 visa, compared to 8,190 in 2008-09 and 5,300 in 2005-06. This figure far exceeded the 3,940 permanent health professionals admitted in 2009-10 through the GSM program. The scale of these arrivals by field was as follows, trending down from the 2008-09 peak of 8,190, at a time when permanent health GSM flows were growing: Medical practitioners: 2,670 in 2009-10 (compared to 3,310 in 2008-09 and 2,120 in 2005-06) Nursing professionals: 2,710 in 2009-10 (compared to 4,070 in 2008-09 and 2,660 in 2005-06) Other health professionals: 640 in 2009-10 (compared to 800 in 2008-09 and 540 in 2005-06) Employer Preference – Sponsorship by Source Country Employers‟ preferred source countries for temporary workers contrasted markedly with the top 10 GSM DIAC-selected source countries (all fields). Between 2005-06 and 2008-09 five of the major English speaking background countries ranked in the top 10 for sponsored workers, in addition to two in West Europe (Germany and France), and one Commonwealth-Asian country (India, characterised by a British-based education system, and significant fluency in English). Put simply, while governments frame skilled migration policy, employers retain the power to offer or withhold work. Temporary worker selection demonstrates the strength of Australian employer preference for high-level English ability (including native speakers), comparable education systems, and perceived capacity to integrate at speed within the labour market. Employers‟ choice of sponsored labour migrants is also aligned to global education ranking systems. For example the Shanghai Jiao Tong listing of the world‟s top 500 institutions (viewed as relatively unbiased) ranked universities as follows by region and country in late 2010: 204 in Europe (overwhelmingly located in North West Europe), including 39 in Germany, 38 in the UK and 22 in France) 187 in the Americas (154 in the US, 23 in Canada, and just 4 in all Central or South America – Chile, Argentina, Mexico) 106 in the Asia-Pacific (34 in China, 25 in Japan, 17 in Australia, 10 in South Korea, 7 in Israel, 5 in New Zealand, 4 in Taiwan, 2 in Singapore, and just 2 in India) 3 in Africa (all in South Africa, with no other African country listed) 1 in the Middle East (Saudi Arabia) 4
Please note that significant delays in sponsorship are reported by state/territory health workforce agencies in relation to the 2010-11 period.
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While China‟s representation on the Shanghai Jiao Tong has grown rapidly in recent years (34 universities listed in 2010 compared to 14 in 2007), there has been no change in relation to India‟s status (just 2 institutions ranked both years)89. Employers‟ sponsorship of migrant health professionals conforms to this general pattern. 15,640 were selected from the major English speaking background countries from 2005-06 to 2009-10 through the 457 visa program (45% of the total). Interestingly (as we have seen) 43% of the health professionals selected as permanent GSM migrants were also from ESB countries (6,900 PA‟s from 2004-05 to 2009-10), in stark contrast to 17% for the total General Skilled Migration program (noting DIAC data were provided by source country for 2004-05 to 2009-10 for permanent skilled migrants compared to 2005-06 to 2009-10 for the 457 visa category). Two-Step Migration Like former international students who migrate to Australia (to be analysed separately in Section 7), substantial numbers of 457 visa temporary workers have been encouraged to remain in Australia in recent years, through a phenomenon known as „two-step migration‟90. (See Table 6 for 2005-06 to 2009-10 GSM and 457 visa source country comparisons.) Table 6: Top 10 Source Countries for Migrant Health Professionals Selected Under the General Skilled Migration Program and the 457 Temporary Program (2005-06 to 2009-10) Top 10 Permanent Source Countries: General Skilled Migration PA’s 2005-06 to 2009-10 (Total All Sources =13,880) 1. UK: 4,120 2. India: 1,510 3. Malaysia: 1,300 4. China: 970 5. Philippines: 510 6. South Africa: 500 7. Republic of Korea: 480 8. Egypt: 420 9. Singapore: 390 10. Ireland: 350
Top 10 Temporary Source Countries: 457 Long-Stay Business Visa PA’s 2005-06 to 2009-10 (Total All Sources =34,870) 1. UK: 9,350 2. India: 6,420 3. Philippines: 1,850 4. South Africa: 1,770 5. Malaysia: 1,570 6. Ireland: 1,560 7. China: 1,380 8. Zimbabwe: 1,180 9. Canada: 950 10. United States: 830
Source: Analysis of unpublished 2009-10 arrivals data provided by the Department of Immigration and Citizenship (May 2011).
In 2004-05 a total of 15,590 sponsored workers converted to permanent resident status across all fields (54% of these male). Four years later this figure had risen to 39,170, reflecting the growth of sponsored flows (including in nursing, medicine and dentistry). From 2004-05 to 2008-09 the primary source countries for 457 visa holders converting to remain in Australia were the UK (30%), South Africa (12%), India (9%), China (6%) and the Philippines (5%). This contrasted with the top 5 source countries for students converting to permanent resident (PR) status at this time: China (28%), India (17%), South Korea (6%), Malaysia (5%) and Indonesia (5%).
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1.3
Trends in Regional Skilled Migration
Migrant Settlement Trends The growing policy input of state/territory governments should be noted briefly at this point. Subnational governments compete to attract and retain the best „regional migrants‟, in order to assure essential workforce supply91. In doing so they face significant challenges. Like Australians, migrants habitually settle in highly skewed sites - in particular capital cities associated with jobs, settlement services, networks, ethnic infrastructure and urban amenity. An identical pattern prevails in New Zealand and Canada. In 2008-09 NSW attracted the largest national migrant share (30% of total arrivals compared to 42% a decade earlier), followed by Victoria (25%), with rapid recent gains made by the mineral-rich states of Queensland and Western Australia92. As illustrated, the remaining states/territories attracted minute immigrant shares at this time, regardless of their sustained aspirations for growth and important historic ethno-specific concentrations (for example, German wine-makers in South Australia, and Pacific Islander and Italian cane-cutters in northern Queensland). Policy Attempts at Dispersal To improve migrants‟ distribution (see Table 7), subnational governments are in the process of being allocated unprecedented policy and operational powers. State/territory sponsored migrants have long been permitted to enter Australia with significantly lower points93. Since 2010 they have been ranked second and third for priority processing (after employer-sponsored migrants). States/territories have now been commissioned to develop skilled migration plans to be coordinated by DIAC, with skill levels and „leakage‟ across state boundaries to be monitored. Table 7: State/Territories of Intended Residence, Settler Arrivals 1998-99 and 2008-09 (All Fields) State/ Territory New South Wales Victoria Queensland Western Australia South Australia ACT Tasmania Northern Territory
1998-1999 % Immigrant Share 41.8 20.5 19.0 12.7 3.9 0.9 0.5 0.6
2008-2009 % Immigrant Share 29.8 25.0 20.9 15.5 6.1 1.2 0.8 0.7
Source: Adapted from Table 1.1, Settler Arrivals 2008-09, Department of Immigration and Citizenship, Canberra (2010), p. 3.
South Australia‟s 2010 plan, for instance, includes a list of 113 preferred occupations. Virtually every health profession is sought, the great majority requiring degree-level qualifications. Indeed, regional workforce supply has been a longstanding concern in Australia94. Engineering is the second priority field, followed by education, information technology and accounting. In policy terms state skilled migration selection criteria now exceed those of the federal government. Three years work experience is mandated for select occupations, plus higher than usual English skills.
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Despite these criteria, employment is not guaranteed. The South Australian government website affirms „State Sponsored migrants must compete with all people in the labour market as part of the normal competitive selection process.‟ 95
1.4
The Role of Skilled Migration Compared to Domestic Health Workforce Training
Overview Within this complex policy environment, what is the role of skilled migration compared to domestic workforce supply? In May 2008 Australia‟s newly elected Labor government confirmed that in future: Long-term labour market needs would be addressed through expanded domestic training; Medium-term needs would be met through permanent skilled migration flows (the GSM); Short-term demand would be satisfied by employer (457 visa) and state/territory sponsored temporary entrants, with both these groups accorded priority processing. Growth in Domestic Capacity Development - Medicine It is important to acknowledge in relation to this that Australia has moved to dramatically expand domestic health workforce supply in the past decade, while attempting to address maldistribution, particularly in medicine. Enrolments in existing medical schools were expanded, while new schools were established in New South Wales (Western Sydney, Wollongong, Notre Dame Sydney), Queensland (Griffith, Bond, James Cook), Victoria (Deakin), the Australian Capital Territory (ANU), and Western Australia (Notre Dame Fremantle) 96. (See Table 8.) Steps were simultaneously taken to address distribution. Scholarships were granted to medical students from regional locations, in line with comparable schemes in the US97. Three main options were introduced in addition to the Rural Students Targeted Access Program (TAP): the Medical Rural Bonded (MRB) Scholarships, the Rural Australian Medical Undergraduate Scholarship Scheme (RAMUS), and the HECS Reimbursement Scheme. Starting from 2001, for example, the MRB scheme created 100 new medical school places annually. Students awarded these scholarships received $20,000 tax-free per year for the duration of their studies. In return they were bonded to work in rural locations for a minimum of six years, having entered a formal contract with the Commonwealth Government with severe non-compliance penalties. These involved repayment of the full amount received with interest, plus the withholding of a Medicare provider number for a period of up to 12 years, less any bonded years of service (a repayment burden halved for defaulting students of rural origin)98. While MRB scholarships were open to all Australian students, RAMUS scholarships (initially 400 in any one year, by 2010 reduced to 120 new annual scholarships) targeted medical students of rural origin, offering living allowances of $10,000 per year reinforced by enrolment in a Rural Doctor Mentorship Scheme 99. The research evidence suggested a positive correlation between student origin and location of future employment100. No penalties were to be applied to trainees subsequently failing to enter rural service101.A third incentive model was the HECS Reimbursement Scheme – one allowing all medical students who agree to work in a rural area one-fifth off their HECS debt for each service year102.
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Table 8: Australian Medical Schools Established by March 2006 University ACT Australian National University New South Wales Sydney New South Wales Newcastle Notre Dame Sydney** Western Sydney* Wollongong** Queensland Queensland Griffith James Cook Bond South Australia Adelaide Flinders Victoria Melbourne Monash Deakin*** Western Australia Western Australia Notre Dame Fremantle Tasmania Tasmania
Entry Type
Course Length
Selection Instruments
Graduate
4
GPA, GAMSAT, Interview (IV)
Graduate Undergraduate Undergraduate Graduate Graduate Undergraduate Graduate Graduate
4 6 5 5 4 5 5 4
GPA, GAMSAT, IV ENTER, UMAT, IV ENTER, UMAT, IV GPA, UMAT, IV GPA, GAMSAT, IV, personal statement ENTER, UMAT, IV GPA, UMAT, IV GPA, GAMSAT, IV
Graduate Graduate Undergraduate Undergraduate
4 4 6 4.6
GPA, GAMSAT, IV GPA, GAMSAT, IV ENTER, IV, large rural and Indigenous quota ENTER, UMAT, IV
Undergraduate Graduate
6 4
ENTER, UMAT, IV GPA, GAMSAT, IV
Undergraduate Graduate Undergraduate Graduate (consideration) Graduate
6 4.5 5 ? 4
ENTER, UMAT GPA, GAMSAT, IV ENTER, UMAT, IV Not yet determined To be determined
Undergraduate Graduate Graduate
6. 4.5 4
ENTER, UMAT, IV GPA, GAMSAT, IV GPA, GAMSAT, IV
Undergraduate
5
ENTER, UMAT
Notes:
Source: S Elliott, Associate Dean (Academic), Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, March 2006 *Commencement planned for 2007, subject to Australian Medical Council approval **Commencement planned for 2008, subject to Australian Medical Council approval ***Federal Government announcement April 2006, to commence 2008 with 120 student places, plus an additional 40 places at Monash
The Federal Government also established a number of new clinical training schools in regional locations. These provide rural oriented training to all medical students. Simultaneously the number of rural training places in the post-graduate RACGP family medicine program was increased. (These measures did not initially involve an accompanying requirement that the doctors emerging actually serve in regional areas.)
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The Human Resource Objectives In 2004 the Australian Health Ministers Conference (AHMC) released the National Health Workforce Strategic Framework. Its vision for the 21st century involved seven principles, designed to develop a workforce which would be: population and health consumer focused, ie. able to deliver safe, appropriate, quality care that maximises health outcomes… and accommodates community expectations, all within a population health framework; sustainable in terms of finance and financial viability, and ensuring there is adequate workforce supply, both now and into the future; distributed to achieve equitable health outcomes: to ensure equitable access to health care regardless of location; suitably trained and competent: ie. appropriately educated with continuing maintenance and improvement of professional competence; flexible and integrated: able to undertake multiple tasks, work in community and/or institution based settings and in multidisciplinary teams…; employable: ie optimal use can be made of available skills and new skills taught; and valued: ie. career satisfaction is maximised and work is undertaken within a supportive environment and culture103. From 2001 to 2005, according to the Australian Institute of Health and Welfare, the greatest growth in domestic education had occurred in relatively low demand fields such as nutrition and dietetics (81%) and pharmacy (48%). Minute increases had occurred in medicine (4%) and nursing (7%) – precisely the fields where demand for immigrants was strong104. Predicted shortages in these fields by 2010 were for 10-13,000 nurses, and 800-1,300 general practitioners105. Following the 2005 Productivity Commission Review of the Australian health workforce, the Council of Australian Governments made a major commitment to health workforce expansion, aligned with the promotion of „workforce mobility and consistency between jurisdictions by creating national registration and accreditation schemes for health professions‟106. Health Workforce Australia has since been charged by the AHMC to develop a National Training Plan. This aims to provide: … the estimated numbers of professional entry, postgraduate and specialist trainees that will be required between 2012 and 2025 to achieve self-sufficiency. Self-sufficiency is defined as a situation in which all of Australia‘s requirements for medical, nursing and midwifery professionals in 2025 can be met from the supply of domestically trained graduates without the need to import overseas trained doctors, nurses and midwives to meet a supply gap107 The scale of Australia‟s interim dependence is high. According to the Australian Institute of Health and Welfare, for instance, by 2009 24.5% of Australia‟s 72,739 medically employed workforce was overseas-trained, including 6% of doctors from the UK/Ireland, 3% from New Zealand, and 16.4% (or 11,948) from „other countries‟. The majority of these international medical graduates (all sources) were concentrated in NSW (5,829), Victoria (3,829), Queensland (3,025), Western Australia (2,858), and South Australia (1,681), with minuscule numbers practising in other territories or states. In 2008-09, based on state and territory medical board/ council data, 17,141 doctors (including IMG‟s) were employed under various forms of conditional registration, most notably in NSW (6,100), Victoria (3,971) and Queensland (2,803). This category covered medical practitioners „not meet(ing) the requirements to become a generally registered medical practitioner‟. Further, 2,695 IMG‟s were employed through „area of need‟ registrations (primarily in Queensland, with 1,351) in a context where Australia had
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become disproportionately reliant on medical migrants for primary health care in outer regional and remote/ very remote sites108. From 2003-04 to 2009-10, according to a recent estimate, 75% of Australia‟s general practice workforce growth was due to migration, compared to 25% from Australian sources109. Growth in Domestic Student Enrolments – Key Fields By 2006 8,318 Commonwealth supported students were enrolled in medical degrees, rising to 11,873 in 2010. The number of domestic full-fee medical students also doubled (from 405 to 905). (See Table 9.) Please note this table includes an underestimate of the number of international medical students enrolled. As will be reported in Section 7 the accurate data for 2009 were 2,772 enrolments, with subsequent rises110. Table 9: Medical Students by Type by Student Place: Number of Places (2006-10) 2006 Medical Students Commonwealth supported HECS only BMPS MRBSS Fee-paying Domestic International (b) Other (c ) Total
2007
8,318 7,144 688 486 2,496 415 2,081 35 10,849
9,017 7,317 1,212 488 2,831 678 2,153 101 11,949
2008 9,878 7,642 1,747 489 3,241 932 2,309 218 13,337
2009
2010
10,938 (a)8,177.5 2,279 (a)481.5 3,373 949 2,424 210 14,521
11,873 8,707 2,686 480 3,356 905 2,451 231 15,460
Source: Medical Deans of Australia and New Zealand Inc. Please note: (a) ANU offers their research component part-time in exceptional circumstances. (b) International students are those studying as private or sponsored students who are not Australian citizens, permanent residents or New Zealand citizens. (c) „Other‟ includes medical students on state health department bonded medical scholarships.
Table 10: Australian Medical and Allied Health Course Completions (2001-09) Medical Graduates Domestic International Total Nursing Domestic International Total Dentistry Domestic International Total
2001
2002
2003
2004
2005
2006
2007
2008
2009
1,203 113 1,316
1,264 161 1,425
1,266 203 1,469
1,287 216 1,503
1,320 267 1,587
1,335 288 1,623
1,544 316 1,860
1,738 401 2,139
1,915 465 2,380
5,084 138 5,222
5,310 297 5,607
5,320 279 5,599
5,631 345 5,976
5,650 453 6,103
6,114 897 7,011
6,683 1,241 7,924
7,186 1,600 8,786
7,266 1,742 9,008
164 29 193
293 56 349
416 53 469
Source: Medical Deans of Australia and New Zealand Inc. and Department of Education, Employment and Workplace Relations (2011).
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As demonstrated in Table 10, domestic student graduations in medicine rose from 1,203 in 2001 to 1,915 in 2009. Comparable expansion was occurring in other fields. Graduations in nursing rose from 5,084 (in 2001) to 7,266 (in 2009). In 2007 164 local students completed Australian dental courses, more than doubling to 416 by 2009 (noting data for dental graduations were available for a more limited period)111. Having established Australia‟s recent skilled migration policy framework, in the context of rising domestic workforce supply, the next section assesses the scale and characteristics of recent migrant health professionals. The focus is on those who are overseas-trained – noting that Australia to 2025 requires early and positive labour market integration outcomes.
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Section 2: Health Workforce Migration to Australia and Employment Outcomes 2.1
Global Demand for Migrant Health Professionals
Eight factors drive the global recruitment of migrant health professionals112. „First, medical and allied health workforces are rapidly ageing in developed countries. As early as 2003, for instance, 42% of Australia‟s surgeons were aged 55 years or more, with the average age of nurses around 50113. Second, health workforce migration is a panacea for short-term domestic shortages. In 2000, for example, the UK‟s National Health Service signed bilateral agreements with India, the Philippines and Spain to contribute to the recruitment of 9,500 medical consultants, 20,000 nurses and 6,500 allied health professionals, while domestic training was being scaled up. By 2005, in consequence, 65% of staff grade doctors, 59% of associate specialists and 43% of senior house officers were „third country trained‟ (derived from beyond the UK and the European Economic Area.)114. Third, international health graduates are sought to compensate for sustained outmigration. In New Zealand, for example, recruitment of 2.3 million migrants in 50 years translated to a net population gain of just 208,000 people. By 2010 1,100 international medical graduates (IMG‟s) were being registered annually compared to just 300 domestic graduates. Fewer than half these IMG‟s would remain for a year, dropping to 31% within a 3 year period115. South Africa has developed a comparable level of dependence on migrant health professionals, to compensate for sustained outflows to the United States, the United Kingdom, Australia, Canada and New Zealand116. Fourth, health workforce recruitment has evolved as a tool to address workforce maldistribution and under-supply. The US, for instance, has a disproportionate reliance on IMG‟s to fill inner-city public sector Medicaid posts117, while in Australia and Canada thousands of IMG‟s and nurses each year are recruited to work in „areas of need‟ – regional and remote sites where visas can be tied to specific locations118. Fifth, countries with limited domestic capacity seek expatriates to provide primary and specialist health care, constituting up to 80% or more of recent physicians in the Gulf States and Botswana. Sixth, vast numbers of health professionals from developing countries seek improved life choices for their children – relocating to OECD nations through single or sequential moves designed to secure better career opportunity, remuneration, and professional conditions (migrating for example from India to the Gulf States to South Africa to Australia within a decade). Seventh, migrant health professionals relocate globally as part of family reunification or refugee flows, a process covering the majority of migrant physicians reaching Germany and the Netherlands for instance, in a context where their presence and workforce
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contribution have not been sought119. (In the case of the Netherlands recent refugee flows have included doctors from the former Yugoslavia, Iran, Iraq, Afghanistan and Somalia.) Finally, what might be termed a „free trade‟ in physicians and allied health professionals exists between OECD countries – major motivations for migration including improved lifestyle, „adventure‟ medicine, and career development. An example is the thousands of UK-trained doctors and nurses accepted by Australia and New Zealand each year, including recently graduated „backpacker doctors‟. A second is the constant shifts south by Canadian health professionals, for example with 8,990 Canadian IMG‟s working in the US by 2005, along with 40,838 IMG‟s from India, 6,687 from China and 3,439 from the UK120.‟ 2.2
Health Workforce Migration to Australia in the Recent Decade
2001-06 Health Workforce Migration (2006 Census) By 2006 Australia had developed an extraordinary level of reliance on migrant health professionals – a fact affirmed by World Health Organisation and OECD analyses121. In its annual 2007 migration report, the OECD stated: Very few countries have specific migration policies for health professionals. Australia is one major exception. The medical practitioner visa (subclass 422) allows foreign nationals… to work in Australia for a sponsoring employer for a maximum of four years. Since April 2003, however, medical practitioners can also apply to the general program for Temporary Business Long Stay (subclass 457). Australia also has specific programmes for attracting foreign health professionals to specific areas. The federal government identifies ‗Districts of Workforce Shortages‘ and states define ‗Areas of need‘ in which foreign-trained doctors may be recruited, temporarily or permanently, sometimes under conditional registration… More generally, there are specific programmes for designated areas (visa 496 or 883) when an occupation is included in the relevant shortage list, which will be generally the case for health professionals. In these designated areas overseas students who have completed their studies in Australia but are unable to meet the pass mark as an independent migrants may be granted a permanent visa (visa 882)122. As established, in the recent decade the scale of medical and allied health migration to Australia has grown markedly through both temporary and permanent flows. By the time of the 2006 Census 53% of residents with dental degrees were overseas-born, compared to 45% qualified in medicine and 25% qualified in nursing. As established in Section 1 this included large numbers of Australia-trained citizens and permanent residents – AIHW and Productivity Commission estimates of international medical and nursing graduates in the Australian workforce being around 25% and 12% of the total. (See Table 11.) Between 2001 and 2006 7,596 migrants with medical qualifications arrived across all immigration categories (compared to 4,392 the previous 5 years), along with 6,680 degreequalified registered nurses and midwives (3,100), 1,125 dentists (540), and multiple migrants qualified in other allied health fields (degrees or diplomas). Within this period India was the primary source of IMG‟s (1,378), followed by the UK/Ireland (1,004), Sri Lanka/Bangladesh (691), China (590), North Africa/Middle East (564), South Africa (496), and other Sub-Saharan Africa (342). The major source countries for degree-qualified nurses/midwives were similar: the UK/Ireland (2,081), the Philippines (1,009), India (455), 59
Japan/South Korea (383), China (356), South Africa (330), and other sub-Saharan Africa (335). An additional 28,352 migrant nurses arrived these years qualified at the diploma or certificate level – certain to have included many RN‟s from the UK, in addition to nurse aides and enrolled nurses. Table 11: Scale of Skilled Migrant Arrivals by Year, Qualification Level and Select Field (2006 Census) Qualification level and field
Australia/ New Zealand born
Overseas-born
All overseasborn
Number (a)
By year of arrival
Pre-1996 19962000
20012006
Degree/Higher degree Information technology Engineering Medicine Dentists Dental technologists Nursing Accounting Business/Commerce Teaching Law Other S/Total
42.8 48.4 54.7 47.4 70.4 75.0 55.7 60.4 75.3 74.4 67.4 64.9
57.2 51.6 45.3 52.6 29.6 25.0 44.3 39.6 24.7 25.6 32.6 35.1
43.9 57.7 62.4 66.8 56.5 72.7 50.9 52.9 69.6 68.3 61.3 59.1
20.6 14.0 12.8 10.8 8.7 9.1 16.4 16.1 11.0 11.2 13.5 14.2
35.5 28.3 24.8 22.4 34.8 18.2 32.7 31.0 19.4 20.5 25.2 26.7
116,535 159,904 72,055 10,040 243 162,314 141,604 324,467 443,203 84,554 786,630 2,301,549
Diploma/Certificate IV Information technology Engineering Medicine Dentists Dental technologists Nursing Accounting Business/Commerce Teaching Law Other S/Total
66.4 72.0 63.0 65.6 79.6 73.7 60.3 75.3 74.0 82.9 71.0 70.4
33.6 28.0 37.0 34.4 20.4 26.3 39.7 24.7 26.0 17.1 29.0 29.6
60.5 77.4 61.6 61.8 75.8 73.5 68.3 67.8 72.0 75.6 75.0 73.4
15.5 8.3 13.0 12.1 11.8 8.8 12.9 11.5 10.8 9.9 9.7 10.6
24.0 14.3 25.4 26.1 12.4 17.7 18.8 20.7 17.2 14.5 15.3 16.0
102,237 365,215 17,117 1,720 22,736 160,180 100,359 349,908 173,832 32,983 9,051,714 10,378,001
Notes: (a) Excludes those for whom birthplace or year of arrival is unknown. Source: Analysis of 2006 Australian Census data, L Hawthorne (2008), Migration and Education: Quality Assurance and Mutual Recognition of Qualifications – Australia Report, UNESCO, http://unesdoc.unesco.org/images/0017/001798/179842E.pdf, Paris.
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Table 12 defines the scale of 2001-06 health professional arrivals by the top 10 fields, focused in this instance solely on recent arrivals active in the workforce (employed or seeking employment). 17,721 migrants met these criteria by 2006 – the great majority qualified at degree level, alongside significant diploma-qualified registered nurse, medical imaging professional and nurse manager entrants. Registered nurses dominated those in the workforce (8,810), followed by medical practitioners (3,200), pharmacists (759), dentists (505), physiotherapists (490) and midwives (418). By 2005, according to the Australian Institute of Health and Welfare, 83% of employed doctors in Victoria were Australia-trained, compared to 81% in Queensland, 74% in Tasmania, 72% in the ACT, 77% in South Australia, and just 66% in Western Australia123. Table 12: Qualification Level of Employed Medical and Allied Health Qualified Migrants in the Workforce by Major Field (2001-06 Arrivals) Field of Qualification 2001-06 1. Registered nurse 2. Medical practitioners 3. Pharmacist 4. Dental practitioner 5. Physiotherapist 6. Midwife 7. Medical imaging prof. 8. Nurse manager 9. Occupational therapist 10. Occup./environ. health 11. Other health Total
Degree/Higher Degree 5,414 3,185 749 494 469 370 259 192 200 115 2,289 13,736
Advanced Diploma/ Diploma/ Certificate 3,396 15 10 11 21 48 112 120 21 77 154 3,985
Total 2001-06 Arrivals 8,810 3,200 759 505 490 418 371 312 221 192 2,443 17,721
Source: Analysis of 2006 Census Data by level and field of qualification, top 10 medical and allied health professions (Australian Bureau of Statistics). Please note this table intentionally excluded recent arrivals who were not in the labour force or were unemployed.
New Zealand Health Workforce Migration It is important to affirm that the scale of New Zealand‟s contribution to Australia‟s health workforce is also large (across all vintages of arrival): Medical practitioners: 1,161 New Zealanders resident in Australia by 2006 Nursing/midwifery: 5,904 Dentistry: 199 Other allied health: 1,892 Total (health qualifications): 9,155 Total New Zealanders resident in Australia (all qualification fields): 237,574 The majority of New Zealand health professionals, even in nursing, were university educated the source for Australia of 3,041 degree-qualified registered nurses and 181 midwives, along with 1,616 diploma-qualified registered nurses/managers/midwives. Many were relatively recent arrivals, including 1,247 nurses, 240 doctors, 44 dentists and 368 other allied health professionals in the 2001-06 period.
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Scale and Distribution of Recent Arrivals Active in the Labour Market by 2006 In line with the settlement patterns noted in Section 1, migrant health professionals‟ spatial location in 2006 was highly uneven. As demonstrated by the Census analysis, 2001-06 arrivals were primarily attracted to NSW, Victoria, Queensland, and Western Australia, with far fewer numbers settling in other states. Queensland was disproportionately dependent on migrants in terms of population size – for example the destination of 1,343 of international medical graduates compared to 1,489 in NSW and 1,032 in Victoria. (See Table 13 for location by key occupation.) Table 13: Location of 2001-06 Migrant Health Professional Arrivals by Key Field by Rank Order (2006) State/ Territory NSW Victoria Queensland WA SA Tasmania ACT NT Total
Medicine
Nursing
Dentistry
Other Allied Health
1,489 1,032 1,343 579 511 184 88 97 5,323
3,351 2,703 1,764 1,746 685 74 153 172 10,648
195 110 148 51 21 8 14 0 547
855 749 643 420 205 78 42 30 3,022
Source: Analysis of 2006 Census Data (Australian Bureau of Statistics data provided to Health Workforce Australia)
Australia‟s expansion of „area of need‟ posts in medicine had improved medical distribution to under-served sites. Essential workforce supply was secured by this means, despite significant debate emerging in recent years on the conditional registration scheme, which allows thousands of temporary resident IMG‟s to work on a supervised basis. Such IMG‟s require substantial occupational bridging – the challenge of delivering this exacerbated by their short term status and remote location. Location was more skewed in relation to nursing and midwifery, with 31% of the total 10,648 migrant arrivals settling in NSW, compared to 25% in Victoria, 17% in Queensland, 16% in Western Australia, but just 6% in South Australia and 0.6% in Tasmania. As demonstrated by Table 14, temporary flows as in medicine had a profound impact on occupational distribution. In 2008-09, for instance, DIAC 457 visa data revealed Victoria to be the major importer of temporary nurses (1,010), followed in rank order by Queensland (780), Western Australia (750) and NSW (610). Migrants‟ practice contribution to regional and remote sites remains critical. As noted in Section 1, the Department of Immigration and Citizenship is intensifying its efforts to distribute skilled migrants. The number of state/territory sponsored GSM entrants doubled from 8,020 in 2004-05 to 14,060 in 2008-09, with an annual target of 24,000 set for both 2010-11 and 2011-12124. By mid-2011 seven state/territory regional subcategories existed, constituting a third of the total permanent General Skilled Migration stream. The 457 temporary visa by contrast had no cap – allowing it to fluctuate annually on an employer demand-driven basis.
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Table 14: Australia’s Sponsorship of Temporary Nurses by State/ Territory by Rank Order (457 Visas Category 2007-08 and 2008-09)
State/Territory Victoria Queensland Western Australia New South Wales South Australia Northern Territory ACT Tasmania Total
2007-08
2008-09
780 890 430 770 260 80 50 20 3,280
1010 780 750 610 420 140 120 30 3,860
Source: Analysis of Department of Immigration and Citizenship statistics on 457 Temporary Resident Arrivals by field (2010)
On-Shore Compared to Off-Shore GSM Selection Australia‟s policy setting currently encourages migrants to enter on a temporary basis, and transition to permanent resident status on-shore. Once dominated by international students (who in 2005 constituted close to half of all „two-step‟ migrants) this option is increasingly being used by mature health professionals. In 2008-09, for example, 440 nurses and 460 allied health professionals secured General Skilled Migration status on-shore, compared to 200 and 270 respectively in 2004-05. (See Table 15.) Most recently this path has been dominated by nurses (600 in 2009-10), followed by pharmacists (250) physiotherapists (40) and dentists (40). A substantial number would have qualified in Australia as international students (including registered nurses‟ completing bachelor-upgrade courses). According to DIAC, recent regional initiatives are designed: ….to provide a streamlined pathway that facilitates the transition from temporary to permanent residence…. (to) make it easier for temporary visa holders who have already made a commitment to living in a regional area and… are filling a skilled position (to stay). Their employers will find it simpler to retain their skills in the region125. The Policy Challenge From a planning perspective the critical issue for governments however is not the scale or location of migrant health professionals but the speed and certainty with those selected find work, including the attributes of those deemed most immediately employable. Significant emphasis is thus placed on early employment outcomes in the field-specific sections to follow, examined first through analysis of 2006 Census data. By definition the Census aggregates all immigration categories (skilled, family and humanitarian). The outcomes achieved by migrants selected under the General Skilled Migration program compared to the family category are next compared, through analysis of Department of Immigration and Citizenship longitudinal survey data. Following this, outcomes for international students qualified in Australia are briefly defined.
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Table 15: General Skilled Migration Arrivals - Health Professional Primary Applicants by Field and Place of Selection – Offshore Compared to Onshore (2004-05 to 2009-10) 2004-05 Profession group Occupation
On
Total
2006-07
2007-08
Off
On
Total
Off
On
Total
Off
On
Total
No. No. No. No. 80
