HEALTH WORKFORCE MIGRATION TO AUSTRALIA

Transcription

1 HEALTH WORKFORCE MIGRATION TO AUSTRALIA Policy Trends and Outcomes Lesleyanne Hawthorne Professor: International Health Workforce Faculty of Medicine, Dentistry and Health Sciences Cleared for Circulation May Scoping Paper Commissioned by Health Workforce Australia

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3 Contents Acknowledgements 5 Tables. 7 List of Acronyms Executive Summary.. 12 Section 1: Australia s Skilled Migration Policy Context Permanent skilled migration to Australia in the Recent Decade Temporary skilled migration and Employer/Regional Sponsorship Trends in regional Skilled Migration The Role of skilled migration compared to Domestic Health workforce training 53 Section 2: Health Workforce Migration to Australia and Employment Outcomes Global demand for migrant health professionals Health workforce migration to Australia in the recent decade Medical practitioners Nurses and midwives Dentists Pharmacists Rehabilitation professionals The role of AHPRA in relation to migrant health professionals 77 Section 3: The Impact of English Testing on Migrant Health Professionals English testing requirements The impact of English language testing in the 1990s The impact of English language testing English language testing 2011 Policy Developments

4 Section 4: Access to Vocational Registration Medicine Pre and post-migration screening Australian Medical Council assessment outcomes IMG survey findings (DoHA study) AMC assessment outcomes to The Competent Authority pathway Additional medical registration pathways Specialist registration overview Specialist registration Surgery (case study 1) Specialist registration Psychiatry (case study 2) Conclusion Section 5: Access to Vocational Registration Allied Health Nurse migration and assessment Dentist migration and assessment Pharmacist migration and assessment Physiotherapist migration and assessment The case for bridging courses Conclusion Section 6: Translation to Practice? Selected Country Profiles Introduction New Zealand United Kingdom/ Ireland South Africa India Malaysia

5 6.7 China Philippines Iran/ Iraq (Other Southern and Central Asia) Egypt Key findings Section 7: International Students as a Health Workforce Resource International students and skilled migration the policy context International enrolments in Australian medical and allied health degrees Source countries and training institutions Skilled migration outcomes for former international students Employment outcomes compared to domestic graduates Employment outcomes for international medical and allied health graduates compared to all other fields Case study former international medical students in Australia Attracting and retaining international students 152 Section 8: The Challenge of Retaining Migrant Health Professionals The emigration of health professionals from Australia The hyper-mobility of international medical graduates Case study 1 - New Zealand Case study 2 Canada Conclusion Section 9: Policy Issues and Research Priorities Key policy issues Future research priorities Endnotes and References

6 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

7 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

8 Executive Summary Tables Table 1: Permanent Immigration Intakes to Australia by Major Category 15 Table 2: Permanent Health Professional Migration GSM Category Arrivals in Rank Order by Select Field ( Compared to , and to Grand Total) 20 Table 3: Temporary Health Professional Migration 457 Temporary Visa Category Arrivals in Rank Order by Select Field ( Compared to Arrivals and Grand Total) 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: Table 2: Level of Australian and Overseas Born Persons Holding Post-School Qualifications (2006), Migrants Grouped by Time of Arrival in Australia, percentages 42 Table 3: Australian Professional Workforce (2006) by Qualification Level and Field, Birthplace and Year of Arrival, percentages 43 Table 4: Permanent Immigration Intakes to Australia by Major Category 44 Table 5: Australian Employer Sponsorship of 457 Visa Long-Stay Workers by Sector ( to ) 48 Table 6: Top 10 Source Countries for Migrant Health Professionals Selected Under the General Skilled Migration Program ( to ) and the 457 Temporary Program ( ) Table 7: State/Territories of Intended Residence, Settler Arrivals and (All Fields) 52 Table 8: Australian Medical Schools Established by March Table 9: Medical Students by Type by Student Place: Number of Places ( ) 56 Table 10: Australian Medical and Allied Health Course Completions ( ) 56 Table 11: Scale of Skilled Migrant Arrivals by Year, Qualification Level and Select Field (2006 Census) 60 Table 12: Qualification Level of Employed Medical and Allied Health Qualified Migrants in the Workforce by Major Field ( Arrivals) 61 Table 13: Location of Migrant Health Professionals by Key Field by Rank Order (2006) 62 Table 14: Australia s Sponsorship of Temporary Nurses by State/Territory by Rank Order (457 Visa Category and ) 63 Table 15: General Skilled Migration Arrivals - Health Professional Primary Applicants by Field and Place of Selection ( to ) 64 Table 16: Labour Market Outcomes for Degree-Qualified Australia/New Zealand-Born Medical Graduates, Compared to Migrant Medical Graduates Arriving (2006) 66 Table 17a: Permanent Health Professional Migration GSM Category Arrivals in Rank Order by Select Field ( Compared to , and to Grand 68 Total) Table 17b: Temporary Health Professional Migration 457 Temporary Visa Category Arrivals in Rank Order by Select Field ( Compared to Arrivals and Grand Total) 68 Table 18: Employment Outcomes and Profession of Primary Applicant by Field for Health Professionals Selected by Skilled Compared to Family Categories (CSAM ) 70 Table 19: Employment Status of Australia/New Zealand Degree-Qualified Nurses, Compared to Overseas-Born Nurse Arrivals (2006 Census) 72 Table 20: Employment Status of Australia/New Zealand Degree-Qualified Dentists, Compared to Overseas-Born Dentist Arrivals (2006 Census) 74 7

9 Table 21: Top 20 Source Countries for Migrant Health Professionals to Australia, Selected through the General Skilled Migration Program, Primary Applicants ( to ) 78 Table 22: Top 20 Source Countries for Migrant Health Professionals to Australia, Selected through the 457 Visa Program, Primary Applicants ( to ) 79 Table 23: Occupational English Test Pass Rates by Region of Origin, Field of Training ( ) 81 Table 24: Occupational English Test Attempts by Key Field ( ) 83 Table 25: Occupational English Test Outcomes by Country of Training ( ) 85 Table 26: MCQ Pass Rate by Region and Age Tertile ( Australian Medical Council Examination Candidates) 92 Table 27: Clinical Examination Pass Rate by Region and Age Tertile ( Australian Medical Council Examination Candidates) 93 Table 28: Australian Medical Council MCQ and Clinical Examination Outcomes by Select Country of Training (1 January 1978 to 31 December 2010) 96 Table 29: Australian Medical Council Clinical Examination Outcomes by Top 10 Countries of Training ( ) 97 Table 30: AMC Competent Authority Pathway Outcomes by Age of Applicant ( ) 99 Table 31: AMC Competent Authority Pathway Outcomes by Top 10 countries of Training ( ) 99 Table 32: AMC Specialist Assessment Pathway Outcomes by Top 10 Countries of Training ( ) 101 Table 33: AMC Specialist Assessment Pathway Outcomes by Top 10 Specialties ( ) 102 Table 34: Australian Nursing and Midwifery Council Applications and Assessment Outcomes for General Skilled Migration (2007 to 2010) 109 Table 35: Australian Dental Council Applications and Assessment Outcomes for Registration (2000 to 2010) 111 Table 36: Australian Physiotherapy Council Assessment Outcomes for Migrant Physiotherapists Who Obtained their APC Certificate (2007 to 2010) 113 Table 37: Labour Market Integration Rates for Migrant Medical, Nursing and Dental Professionals in the First 5 Years Post-Migration (2006 Census) 116 Table 38: Scale of Health Workforce Migration by Select Birthplace, by Period of Arrival (2006 Census) 118 Table 39: Growth in Undergraduate International Student Enrolments in Australian Universities in the Medical/Health Sciences: Table 40: Trends in International Student Demand for Australian Medical and Allied Health Courses by Major Source Countries (2009) 134 Table 41: Top 10 Source Countries for UG and PG International Students in Australian Dental Science Courses (2000 and 2009) 135 Table 42: Top 10 Source Countries for UG and PG International Students in Australian Medicine Courses (2004 and 2009) 135 Table 43: Top 10 Source Countries for UG Post-Basic and PG International Students in Australian Post-Basic Nursing Courses (2000 and 2009) 135 Table 44: Top 10 Source Countries for UG and PG International Students in Australian Physiotherapy Courses (2000 and 2009) 136 Table 45: Top Institutions of Training for International Students Enrolled in Australian Entry to Practice Medical Courses (2009) 136 Table 46: Top Institutions of Training for International Students Enrolled in Australian Basic Undergraduate Nursing Courses (2009) 137 Table 47: Top Institutions of Training for International Students Enrolled in Australian Post-Basic 137 8

10 Undergraduate Nursing Courses (2009) Table 48: Top Institutions of Training for International Students Enrolled in Australian Undergraduate Dental Courses (2009) 137 Table 49: Employment Status of Skilled and Family Primary Applicants by Australian Qualification and Grant Location (for Migrants Selected March 2008 to October 2009) 139 Table 50: Intention to Stay in Australia Following Medical Graduation (MSOD 2009) 141 Table 51: Employment Outcomes for Former International Medical Students in Australia Compared to Domestic Graduates Four Months Following Course Completion ( ) 142 Table 52: Employment Outcomes for former International Nursing Students in Australia Compared to Domestic Graduates four Months Following Course Completion ( ) 143 Table 53: Employment Outcomes for former International Dental Students in Australia Compared to Domestic Graduates four Months Following Course Completion ( Table 54: Employment Outcomes for Former International Physiotherapy Students in Australia Compared to Domestic Graduates four Months Following Course Completion ( ) 145 Table 55: Median Annual salaries ($AUD) for Australian Graduates Working Full-Time in Australia by Select Field, Domestic compared to Non-Permanent Resident ( ) 146 Table 56: Victorian Internship Destinations for International Students Graduating from the University of Melbourne MBBS Degree ( ) 148 Table 57: Victorian Internship Destinations for International Students Graduating from the University of Melbourne MBBS Degree (2011 for 2010 Graduates) 149 Table 58: Emigration of Health Professionals from Australia, by Gender and Age ( to ) 153 Table 59: Emigration of Health Professionals from Australia, by Country of Birth ( to ) 154 Table 60: Emigration of Australia-Born and Migrant Health Professionals from Australia, by State/Territory ( to Table 61: Relocations Reported by a Random Sample of IMG s in the Interview Research Sample 157 Table 62: The Scale of Health Workforce Migration to Canada 2007 and 2008 Skilled category Permanent and Temporary Residents by Field

11 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

12 TOEFL TR Test of English as a Foreign Language Temporary Resident 11

13 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 professionals 1. 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 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 ,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 period 4. 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 Zealand 5. 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 posts 6, 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 locations 7. 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

14 contribution have not been sought 8. (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 UK 9. 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 strategies 10. 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

15 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 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 Lanka 12. 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 to , 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 , 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 ,100 permanent migrants were selected in the General Skilled Migration (GSM) category, compared to 27,550 in 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 and , 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 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

16 Table 1: Permanent Immigration Intakes to Australia by Major Category Program Numbers by Stream Plan Family 44,580 32,040 38,090 50,080 49,870 56,500 60,300 54,550 Skilled 27,550 35,000 53,520 97, , , , ,850 Additional Skilled* c5,000 Special Eligibility 1, , Humanitarian 11,900 11,356 12,349 13,017 13,000 13,500 13,750 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 : Immigration, Parliament of Australia, accessed 21 August 2011*. An additional 100, ,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, arrivals were primarily attracted to NSW, Victoria, Queensland, and Western Australia, with few migrant professionals settling in other states. In 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 Australia 15. 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 points 16. The number selected by states doubled from 8,020 in to 14,060 in , with annual targets of 24,000 set for and (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 qualifications 18. 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

17 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 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 gap 20 The scale of Australia s interim dependence is high. According to the Australian Institute of Health and Welfare, for instance, by % 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 , 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 sites 21. 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)

18 Domestic medical graduations: By ,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 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) 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 graduates 1. 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. 1 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. 17

19 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 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 component 25. 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 to ,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). 18

20 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 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 ,940 migrant health professionals were selected as permanent GSM migrants, compared to 2,870 in and 2,480 in (with the peak year). From to a total of 15,940 were admitted, with key trends as follows: Medical practitioners: 1,070 selected in (compared to 450 in and just 180 in ). Nursing professionals: 1,700 selected in (compared to 1,360 in and 1,470 in ). Other health professionals: 1,170 selected in (compared to 1,070 in and 830 in ) - in particular pharmacists (560 in ), dentists (180 in ), and physiotherapists (130 in ). (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 to were the United Kingdom (4,960), India (1,610), Malaysia (1,470), China (1,030), South Africa (580), the Philippines (570), the 19

21 Republic of Korea (540), Egypt (430), Singapore (470), and Ireland (410). Most selected for admission in were female (63% of the total, reflecting the dominance of nursing). The majority were of prime workforce age (34% aged years, 27% aged 30-34, and 16% aged 30-39, while 8% were new graduates aged 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 ( Compared to , and to Grand Total) Select Field GSM GSM GSM GSM Total to Nursing 1,470 1,360 1,700 8,250 Medicine ,070 2,330 Pharmacy ,080 Dentistry Physiotherapy Grand Total (All Fields) 2,480 2,870 3,940 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 to , compared to 15,940 for the GSM from to (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 working

22 Migration Scale by Field The 457 visa option has proven highly attractive to migrants, employers and governments. In 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 ,020 migrant health professionals were sponsored by Australian employers on the 457 visa, compared to 8,190 in and 5,300 in From to a total of 34,870 arrived. The scale by field was as follows, trending down from Australia s peak of 8,190, at a time when permanent health GSM flows were growing: Medical practitioners: 2,670 in (compared to 3,310 in and 2,120 in ). Nursing professionals: 2,710 in (compared to 4,070 in and 2,660 in ). Other health professionals: 640 in (compared to 800 in and 540 in ), in particular dentists (150 in ), physiotherapists (90 in ) and pharmacists (20 in ). (See Table 3.) Table 3: Temporary Health Professional Migration 457 Temporary Visa Category Arrivals in Rank Order by Select Field ( Compared to Arrivals and Grand Total) Select Field 457 Visa Visa Visa Visa Total to Nursing 2,660 4,070 2,710 15,960 Medicine 2,120 3,310 2,670 15,490 Dentistry Physiotherapy Pharmacy Grand Total (All Fields) 5,300 8,190 6,020 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 to ) in marked contrast to an extraordinary 2,080 selected from to 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 to % 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). 21

23 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 to , 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 ). 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 anguish 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. 22

24 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 Victoria 30. In ,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 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 % 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 By Semester enrolments had grown to around 3,000, with an estimated 70% of former international students transitioning on graduation to internships 32. Dentistry and Physiotherapy: 387 international students were enrolled in Australian entry to practice dental degrees in 2009 compared to 98 in 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

25 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 registerability 35. 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 ,680 degreequalified nurses migrated to Australia, compared to 3,100 from (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 demand 36. 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 24

26 (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 norm 37. (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). 25

27 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 In % 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 % 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 % 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). 26

28 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 % 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 % of available former students were employed in dentistry full-time, compared to 95% in 2008 and 94% in 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 % 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 % 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

29 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 job 38. 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 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 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 28

30 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 to assess the test s impact the first such in-depth analysis 40. Within the period studied, 24,683 health professionals had attempted one or more modules of the test, with multiple attempts the norm 2. 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 (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 The difference was stark for medically qualified migrants from 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 candidates 3. 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 In % 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. 29

31 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 ,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 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 Doctors 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 Doctors 42. From to ,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 % 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, 30

32 Iraq and Egypt but 38% for Filipino candidates). Demand for AMC exams however is increasing. In ,466 candidates attempted the MCQ, compared to 1,509 in Clinical attempts similarly rose from 887 to 1,258 within this period. Age was a critical variable in relation to AMC pass rates. From % of IMG s aged years passed the MCQ on their first attempt, compared to 46% aged 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 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 databases 43. 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 program 44. 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 ,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 competitiveness 45. From the Competent Authority pathway attracted relatively young applicants, with 54% of those issued Advanced Standing Certificates aged years compared to 38% aged 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 , 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 ,612 IMG specialist assessment applications were received by the 31

33 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 years, 6,093 aged years, 3,876 aged years, 968 aged 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 , 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 hurdles 46. 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 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

34 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: ). 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/Bangladesh 47. 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 ,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 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

35 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 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 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 years 50. According to the Medical Council of New Zealand 51, $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

36 (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 outcomes 52. 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) 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 resource 54. 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. 35

37 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 to In ,875 health professionals emigrated permanently from Australia, compared to 2,203 in 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 (compared to 424 in ) Nursing: 1,274 permanent departures in (compared to 988 in ) Dentistry: 53 permanent departures in (compared to 70 in ) Physiotherapy: 174 permanent departures in (compared to 103 in ) Pharmacy: 123 permanent departures in (compared to 81 in ) Other allied health professions: 711 permanent departures in (compared to 537 in ) 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 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 report 55. 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 studies 56. 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 care 57. 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

38 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 work 58. 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 37

39 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). 38

40 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. 39

41 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 Medicare 59. 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

42 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 work 60. 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 Base Population (15-24 years) No. of Medical Students *Participation Rate Malaysia 22, % Hong Kong 20, % Vietnam 33, % UK & Ireland 76, % Greece 3, % Lebanon 11, % Philippines 11,761 4, % Australia 2,336,377 4, % All overseas born 409,781 2, % 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 representation 61. 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

43 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 categories 62. 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 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 Birthplace Arrival time Gender Qualifications Doctoral Master/ Postgraduate Australia Male Female All Grad Diploma/ Grad Certificate Batchelor Advanced Diploma/ Diploma Certificate/ No Post- School Qualifications Total (a) Number (a) Overseas Pre-1996 Male Female All Male Female All Male Female All S/Total arrivals Male Female All 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. Within the past decade the impact of migration on key Australian professions has become profound. By % 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

44 and by the Australian Institute of Health and Welfare in 2004 and ). 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. Table 3: Australian Professional Workforce (2006) by Qualification Level and Field, Birthplace and Year of Arrival, percentages Qualification level and field Australia -born All overseasborn Overseas-born By year of arrival Pre Total (a) Number (a) Degree/Higher degree Information technology ,523 Engineering ,940 Medicine ,068 Nursing ,372 Accounting/Business/Commerce ,062 Teaching ,231 Law ,515 Other ,210 S/Total ,314,921 Diploma/Advanced Diploma/Certificate IV Information technology ,240 Engineering ,195 Medicine ,138 Nursing ,148 Accounting/Business/Commerce ,792 Teaching ,837 Law ,981 Other ,669,456 S/Total ,958,787 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. 43

45 In ,578 New Zealanders reached Australia as settlers, compared to 18,677 in , 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 years 66. As demonstrated in Section 2 of this study, large numbers are qualified in the health professions arrivals including 1,247 New Zealand nurses/midwives, 368 qualified in other allied health fields, 240 in medicine and 44 in dentistry 67. 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 and , 358,151 permanent GSM migrants were selected, including 72,172 people in (counting dependents). Skilled migration constituted two-thirds of Australia s immigration program at this time. In a target of 182,450 permanent arrivals was set, split between the following categories 68 : Skilled 108,100 (59%) Family 60,300 (33%) Humanitarian 13,750 (8%) For 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 Plan Family 44,580 32,040 38,090 50,080 49,870 56,500 60,300 54,550 Skilled 27,550 35,000 53,520 97, , , , ,850 Special Eligibility 1, , Humanitarian 11,900 11,356 12,349 13,017 13,000 13,500 13,750 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 : Immigration, Parliament of Australia, accessed 21 August 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 year of arrival). Very little is known of their partners, despite these being accorded the right to work. 44

46 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 component 69. 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 basis 70. Between and ,405 Independent primary applicants 71 with family arrived - the dominant entry pathway for the past 3 decades 72. 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 professionals 73 : 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 to two-thirds of GSM primary applicants were male (63%) - the great majority of prime workforce age, with 18% aged 15-24, 57% and 23% 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 compared to 39% five years earlier. Near gender equity prevailed however in the GSM program overall, with women contributing 46% of to 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

47 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 to ,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 the latest General Skilled Migration data showing the following arrivals by field: Nursing: 1,700 GSM PA s (compared to 1,360 in ) 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 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 and 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 and a total of 72,841 UK migrants reached Australia 75, 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 for GSM health-qualified arrivals were: 1. UK: 960 or 24% (compared to 800 in ) 46

48 2. India: 610 or 15% (compared to 350) 3. Malaysia: 380 or 10% (compared to 320) 4. China: 360 or 9% (compared to 200) 5. Egypt: 190 or 5% (compared to 90) 6. South Africa: 130 or 3% (compared to 110) 7. Philippines: 130 or 3% (compared to 120) 8. Republic of Korea: 110 or 3% (compared to 90) 9. Singapore: 100 or 2% (compared to 60) 10. 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 were female (63% of the total). The majority were of prime workforce age: 34% aged years, 27% aged 30-34, and 16% aged 30-39, while 8% were new graduates aged 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 migrants 78. 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

49 The Recent Scale of Temporary Labour Migration 457 Visa From to 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 labour 81. This form of admission was highly relevant to the health professions. Annual numbers surged - from 48,610 people in including dependents to 110,570 arrivals in , moderating to 101,280 in 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 ( to ) Industry Sector (457 Visa Sponsorship) Employer-Sponsored Arrivals June 2007-June 2008 Growth Trend Compared to Arrivals Health/ community services 9, % Property/ business services 6, % Construction 5, % Manufacturing 5, % Communication services 5, % Mining 4, % Accommodation/ hospitality 3, % Finance/ insurance 3, % Education 2, % Retail trade 1, % 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 streams 82. 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 working 83. 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

50 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 accreditation 84. 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 ). 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 Victoria 87. 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 to % 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

51 Growth by occupational sector was particularly dynamic from to , 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 professionals 4. As early as 1999 the Australian Medical Workforce Advisory Committee published a report on temporary resident doctors in Australia 88. By ,020 migrant health professionals were sponsored by Australian employers on the 457 visa, compared to 8,190 in and 5,300 in This figure far exceeded the 3,940 permanent health professionals admitted in through the GSM program. The scale of these arrivals by field was as follows, trending down from the peak of 8,190, at a time when permanent health GSM flows were growing: Medical practitioners: 2,670 in (compared to 3,310 in and 2,120 in ) Nursing professionals: 2,710 in (compared to 4,070 in and 2,660 in ) Other health professionals: 640 in (compared to 800 in and 540 in ) 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 and 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 period. 50

52 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 to 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 to ), in stark contrast to 17% for the total General Skilled Migration program (noting DIAC data were provided by source country for to for permanent skilled migrants compared to to 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 to 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 ( to ) Top 10 Permanent Source Countries: General Skilled Migration PA s to (Total All Sources =13,880) 1. UK: 4, India: 1, Malaysia: 1, China: Philippines: South Africa: Republic of Korea: Egypt: Singapore: Ireland: 350 Top 10 Temporary Source Countries: 457 Long-Stay Business Visa PA s to (Total All Sources =34,870) 1. UK: 9, India: 6, Philippines: 1, South Africa: 1, Malaysia: 1, Ireland: 1, China: 1, Zimbabwe: 1, Canada: United States: 830 Source: Analysis of unpublished arrivals data provided by the Department of Immigration and Citizenship (May 2011). In 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 to 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%). 51

53 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 supply 91. 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 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 Australia 92. 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 points 93. 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 and (All Fields) State/ Territory % Immigrant Share % Immigrant Share New South Wales Victoria Queensland Western Australia South Australia ACT Tasmania Northern Territory Source: Adapted from Table 1.1, Settler Arrivals , 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 Australia 94. 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. 52

54 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 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 US 97. 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 employment 100. No penalties were to be applied to trainees subsequently failing to enter rural service 101.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 year

55 Table 8: Australian Medical Schools Established by March 2006 University Entry Type Course Length Selection Instruments ACT Australian National University Graduate 4 GPA, GAMSAT, Interview (IV) New South Wales Sydney Graduate 4 GPA, GAMSAT, IV New South Wales Undergraduate 6 ENTER, UMAT, IV Newcastle Undergraduate Graduate 5 5 ENTER, UMAT, IV GPA, UMAT, IV Notre Dame Sydney** Graduate 4 GPA, GAMSAT, IV, personal statement Western Sydney* Undergraduate Graduate 5 5 ENTER, UMAT, IV GPA, UMAT, IV Wollongong** Graduate 4 GPA, GAMSAT, IV Queensland Queensland Graduate 4 GPA, GAMSAT, IV Griffith Graduate 4 GPA, GAMSAT, IV James Cook Undergraduate 6 ENTER, IV, large rural and Indigenous quota Bond Undergraduate 4.6 ENTER, UMAT, IV South Australia Adelaide Undergraduate 6 ENTER, UMAT, IV Flinders Graduate 4 GPA, GAMSAT, IV Victoria Melbourne Undergraduate Graduate ENTER, UMAT GPA, GAMSAT, IV Monash Undergraduate Graduate (consideration) 5? ENTER, UMAT, IV Not yet determined Deakin*** Graduate 4 To be determined Western Australia Western Australia Undergraduate Graduate ENTER, UMAT, IV GPA, GAMSAT, IV Notre Dame Fremantle Graduate 4 GPA, GAMSAT, IV Tasmania Tasmania 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.) 54

56 The Human Resource Objectives In 2004 the Australian Health Ministers Conference (AHMC) released the National Health Workforce Strategic Framework. Its vision for the 21 st 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 culture 103. 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 strong 104. Predicted shortages in these fields by 2010 were for 10-13,000 nurses, and 800-1,300 general practitioners 105. 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 gap 107 The scale of Australia s interim dependence is high. According to the Australian Institute of Health and Welfare, for instance, by % 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 , 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 55

57 become disproportionately reliant on medical migrants for primary health care in outer regional and remote/ very remote sites 108. From to , according to a recent estimate, 75% of Australia s general practice workforce growth was due to migration, compared to 25% from Australian sources 109. Growth in Domestic Student Enrolments Key Fields By ,318 Commonwealth supported students were enrolled in medical degrees, rising to 11,873 in 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 rises 110. Table 9: Medical Students by Type by Student Place: Number of Places ( ) Medical Students Commonwealth supported 8,318 9,017 9,878 10,938 11,873 HECS only 7,144 7,317 7,642 (a)8, ,707 BMPS 688 1,212 1,747 2,279 2,686 MRBSS (a) Fee-paying 2,496 2,831 3,241 3,373 3,356 Domestic International (b) 2,081 2,153 2,309 2,424 2,451 Other (c ) Total 10,849 11,949 13,337 14,521 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 ( ) Medical Graduates Domestic 1,203 1,264 1,266 1,287 1,320 1,335 1,544 1,738 1,915 International Total 1,316 1,425 1,469 1,503 1,587 1,623 1,860 2,139 2,380 Nursing Domestic 5,084 5,310 5,320 5,631 5,650 6,114 6,683 7,186 7,266 International ,241 1,600 1,742 Total 5,222 5,607 5,599 5,976 6,103 7,011 7,924 8,786 9,008 Dentistry Domestic International Total Source: Medical Deans of Australia and New Zealand Inc. and Department of Education, Employment and Workplace Relations (2011). 56

58 As demonstrated in Table 10, domestic student graduations in medicine rose from 1,203 in 2001 to 1,915 in Comparable expansion was occurring in other fields. Graduations in nursing rose from 5,084 (in 2001) to 7,266 (in 2009). In 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. 57

59 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 professionals 112. 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 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 ,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 period 115. 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 Zealand 116. 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 posts 117, 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 locations 118. 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 58

60 contribution have not been sought 119. (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 UK Health Workforce Migration to Australia in the Recent Decade 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 analyses 121. 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 ,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

61 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 By year of arrival Pre Number (a) Degree/Higher degree Information technology ,535 Engineering ,904 Medicine ,055 Dentists ,040 Dental technologists Nursing ,314 Accounting ,604 Business/Commerce ,467 Teaching ,203 Law ,554 Other ,630 S/Total ,301,549 Diploma/Certificate IV Information technology ,237 Engineering ,215 Medicine ,117 Dentists ,720 Dental technologists ,736 Nursing ,180 Accounting ,359 Business/Commerce ,908 Teaching ,832 Law ,983 Other ,051,714 S/Total ,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, Paris. 60

62 Table 12 defines the scale of 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 Australia 123. Table 12: Qualification Level of Employed Medical and Allied Health Qualified Migrants in the Workforce by Major Field ( Arrivals) Field of Qualification Degree/Higher Degree Advanced Diploma/ Diploma/ Certificate Total Arrivals 1. Registered nurse 5,414 3,396 8, Medical practitioners 3, , Pharmacist Dental practitioner Physiotherapist Midwife Medical imaging prof Nurse manager Occupational therapist Occup./environ. health Other health 2, ,443 Total 13,736 3,985 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 period. 61

63 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, 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 Migrant Health Professional Arrivals by Key Field by Rank Order (2006) State/ Medicine Nursing Dentistry Other Allied Health Territory NSW 1,489 3, Victoria 1,032 2, Queensland 1,343 1, WA 579 1, SA Tasmania ACT NT Total 5,323 10, ,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 , 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 to 14,060 in , with an annual target of 24,000 set for both and 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. 62

64 Table 14: Australia s Sponsorship of Temporary Nurses by State/ Territory by Rank Order (457 Visas Category and ) State/Territory Victoria Queensland Western Australia New South Wales South Australia Northern Territory ACT Tasmania Total 3,280 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 , for example, 440 nurses and 460 allied health professionals secured General Skilled Migration status on-shore, compared to 200 and 270 respectively in (See Table 15.) Most recently this path has been dominated by nurses (600 in ), 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 region 125. 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. 63

65 Table 15: General Skilled Migration Arrivals - Health Professional Primary Applicants by Field and Place of Selection Offshore Compared to Onshore ( to ) Profession group Occupation Off On Total Off On Total Off On Total Off On Total Medical Practioners Nursing Professionals Other Health Professionals No. No. No. No. No. No. No. No. No. No. No. No. General Medical Practitioner 80 < < < Specialist Medical Practitioners Medical Practioners Total 120 < < < Registered Nurses Registered Midwives < < < 5 40 Other nursing professionals < 5 0 < Nursing Professionals Total Dentistry Physiotherapy Pharmacy Other allied health professionals Other Health Professionals total Total Source: Department of Immigration and Citizenship, 2011 (BE ) Off = Offshore; On = Onshore Note 1: Data is for principal applicants only Note 2: Figures have been rounded to the nearest 10 Note 3: Health professionals includes ASCO Minor Group 231, 232, 238, 239 and

66 Table 15 (Cont.): General Skilled Migration Arrivals - Health Professional Primary Applicants by Field and Place of Selection - Offshore Compared to Onshore ( to ) Profession group Occupation Off On Total Off On Total Off On Total Medical Practioners Nursing Professionals Other Health Professionals Total No. No. No. No. No. No. No. No. No. General Medical Practitioner 350 < < Specialist Medical Practitioners Medical Practioners Total 450 < < Registered Nurses Registered Midwives 50 < < Other nursing professionals < 5 0 < Nursing Professionals Total Dentistry Physiotherapy Pharmacy Other allied health professionals Other Health Professionals total Total Source: Department of Immigration and Citizenship, 2011 (BE ) Off = Offshore; On = Onshore Note 1: Data is for principal applicants only Note 2: Figures have been rounded to the nearest 10 Note 3: Health professionals includes ASCO Minor Group 231, 232, 238, 239 and

67 2.3 Medical Practitioners Early Employment Outcomes by Source Country 2001 Compared to 2006 By 2001 migrant health professionals integration occurred fairly swiftly in Australia relative to key competitor countries. For example a study commissioned by the Canadian government demonstrated just 19% of Indian doctors admitted from were medically employed in Canada by 2001 (compared to 66% in Australia), 31% from Hong Kong/ Malaysia/Singapore (compared to 59%), and 8% from Eastern Europe (compared to 24%) 126. Despite this, identical medical elites were advantaged in each country (eg 81% of South African doctors employed in medicine in their first 5 years), while doctors qualified in China suffered severe skills discounting (just 4-5% securing work in medicine differences in language and training systems constituting major barriers). As demonstrated in the 2011 House of Representatives Inquiry into the Registration Processes and Support for Overseas Trained Doctors in relation to medicine, employment dislocation is a matter of personal and professional anguish 127. Within this context it is important to assess the employment outcomes achieved by medical arrivals in Australia, based on analysis of 2006 Census data. By 2006, as noted, 45% of residents with medical qualifications were overseas-born, including Australia-trained citizens/ permanent residents admitted as children. (See Section 1.) A total of 7,596 overseas trained doctors had migrated from 2001 to 2006, across all immigration categories. India, the UK/Ireland, Other Europe, Sri Lanka/Bangladesh, China, North Africa/Middle East, South Africa, the Philippines, Malaysia and China were the major recent source countries. (See Table 16.) Table 16: Labour Market Outcomes for Degree-Qualified Australia/ New Zealand-Born Medical Graduates, Compared to Migrant Medical Graduates Arriving (2006) Arrival Date Employed Other Percentage Number Birth Own Other Other Sub- (b) Country Prof Prof Work Total Unemp NLF Australia/New Zealand ,381 Arrived UK/Eire (Ireland) Northern Europe Western Europe South Eastern Europe Eastern Europe Viet Nam Indonesia Malaysia Philippines Singapore China (Not SARs/Taiwan) Hong Kong/Macau Japan/South Korea Other Southern and Central Asia India Sri Lanka/Bangladesh Canada/USA Central/South America Other Sub-Sahara Africa South Africa North Africa/Middle East Other Total migrants Notes: Excludes those for whom birthplace or year of arrival is unknown. a = Many of the cells are based on very small numbers, therefore the results should be regarded as indicative only. Empty cells are where there are insufficient cases for reliable reporting and issues of confidentiality. E.g. there were just 14 degree-qua b = Due to missing data, imputation and aggregation, numbers may not add up to 100%. Source: Analysis of 2006 Australian Census data, L Hawthorne (2008), Migration and Education: Quality Assurance and Mutual Recognition of Qualifications Australia Report, UNESCO, Paris. 66

68 Australia s diversification of medical workforce supply has proven challenging. By 2006, just 53% of IMG s had secured medical employment in their first 5 years. Those best placed were derived from South Africa (75%), the UK/Ireland and Other Sub-Saharan Africa (both 71%), Singapore and Malaysia (62%), India and Western Europe (61%). As in 2001, outcomes were poor by contrast for a range of birthplace groups with just 6% of doctors from China medically employed within 5 years, along with 23% from Vietnam and 31% from Eastern Europe. Many of these doctors had reached Australia within the family and humanitarian categories untested in advance for their employment attributes and registerability 128. Substantial numbers were also defined as not in the labour force (NLF) in 2006 a proxy for learning English and attempting to satisfy pre-registration hurdles. Fifty-nine percent of Indonesian doctors fell into this category, in addition to 48% from Japan/South Korea, 47% from Vietnam, 38% from Eastern Europe, and 36% from China. Filtering for Employability - Skilled Category Selection Criteria in the Past Decade Employment outcomes were best for international medical graduates selected by DIAC through the General Skilled Migration program, or by employers via temporary sponsored pathways. As we have seen, 43% of GSM health professionals from to were derived from the major English speaking background countries (comparable with the 457 visa category, and far higher than Australia s 17% GSM norm). Since 1999 GSM primary applicants 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 across all four skills required). Mandatory pre-migration credential assessment, conducted by the relevant Australian regulatory bodies for each vocational field. 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) 129. This selection process applies to all GSM fields. State/Territory Dependence on IMG s for Regional Service Provision From to ,489 IMG s arrived as skilled category PA s in Australia, rising to 2,593 once partners were included. From to a total of 2,330 medically qualified primary applicants arrived in all, based on 1,830 general practitioners and 520 specialists. Temporary flows were also strong - highly attractive to state/territory governments and employers given the potential to prescribe IMG s location as a condition of entry. From June 2000 to December 2002, 5,304 temporary IMG s were allocated to areas of need, often sponsored to 67

69 remote locations in the states of Queensland (2,049), Western Australia (1,204) and Victoria (1,176) 130. This level of dependence has been maintained - in the source of 3,860 IMG s selected by states/territories compared to 3,310 in The most recent data for show a sudden surge in permanent resident GSM medical migration but a modest drop in those sponsored on a temporary resident basis, as follows: GSM: 1, medical arrivals (compared to 450 in and 180 in ) 457 Long-Stay Business Visa: 2, arrivals (compared to 3,310 in and 2,120 in ) See Tables 17a and 17b for a comparison of the scale of recent GSM and 457 visa arrivals by select field (noting that data from were also provided for GSM health professionals). Table 17a: Permanent Health Professional Migration GSM Category Arrivals in Rank Order by Select Field ( Compared to , and to Grand Total) Select Field GSM GSM GSM GSM Total to Nursing 1,470 1,360 1,700 8,250 Medicine ,070 2,330 Pharmacy ,080 Dentistry Physiotherapy Grand Total (All Fields) 2,480 2,870 3,940 15,940 Source: Analysis of unpublished Department of Immigration and Citizenship flows data, provided to HWA. Table 17b: Temporary Health Professional Migration 457 Temporary Visa Category Arrivals in Rank Order by Select Field ( Compared to Arrivals and Grand Total) Select Field 457 Visa Visa Visa Visa Total to Nursing 2,660 4,070 2,710 15,960 Medicine 2,120 3,310 2,670 15,490 Dentistry Physiotherapy Pharmacy Grand Total (All Fields) 5,300 8,190 6,020 34,870 Source: Analysis of unpublished Department of Immigration and Citizenship flows data, provided to HWA. 68

70 Australia s Level of Dependence on International Medical Graduates: Three Case Studies 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%). 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 According to Health Workforce Queensland, by % of doctors in rural and remote practice in Queensland were overseas-trained - primarily qualified in the UK (20%), India (15%), South Africa (12%), the Philippines, New Zealand, Pakistan and Sri Lanka. While many had permanent resident status or were citizens (as in other states), 13% were temporary resident arrivals (207), typically employed in practice with limited registration 132. The quality of their skills and employment outcomes thus mattered. Longitudinal Survey Data on Migrant Health Professionals Employment Outcomes - DIAC Within this policy context, it is important to briefly assess the early employment outcomes achieved by international medical graduates selected through Australia s GSM program. Two major DIAC data sources exist, not previously analysed in relation to health workforce migration. The first is the Longitudinal Survey of Immigrants to Australia (the LSIA). Commencing with a pilot survey in 1992, the LSIA has been administered three times (in , and ), to a weighted representative sample of PA s and secondary applicants. For LSIA 3, a short mail-out survey was administered at 6 months, followed by a telephone interview at 18 months. Analysis of DIAC s Longitudinal Survey on Immigrants to Australia 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. At 18 months 89% were employed just 18% stating they had experienced unemployment in the previous year. By this stage 70% were working in their preferred occupation, with impressive mobility rates and salary gains also reported 133. It should be noted that the LSIA survey contained very modest numbers of migrant health professionals (145 respondents in all), with 94 GSM PA s compared to 51 family category health professionals. By definition cell sizes were thus minute or very small, with implications for the robustness of any analysis: Medicine: 12 GSM PA s and 17 family category migrants (29 total) Nursing: 54 GSM PA s and 20 family category migrants (74) Dentistry: 3 GSM PA s and 5 family category migrants (8) Pharmacy: 12 GSM PA s and 4 family category migrants (16) Rehabilitation: 13 GSM PA s and 5 family category migrants (18) Given this, field-specific LSIA data analyses were conducted but are not reported on here. 69

71 IMG s Employment Outcomes at 6 Months ( CSAM) The second DIAC data source available for analysis, the Continuous Survey of Australia s Migrants (the CSAM), was introduced in 2009 after piloting, and involved 6 month surveys of new cohorts of migrants on an ongoing basis. Like the LSIA, the CSAM focused on skilled migration and family streams its aim being to assess early labour market outcomes 134. In all there were 7,216 respondents to the CSAM waves administered in October 2009 and April 2010 (all fields). A weighted sample of 5,200 health professionals were represented, based on a population of 71,790 skilled and family category migrants. Examination of the CSAM allows insight into medical migrants speed of access to professional employment, noting that weighted data here were collected in October 2009 and April Responses from the equivalent of 720 IMG s were available for analysis (translating to around 70 actual informants). 680 were employed in medicine at 6 months, compared to 40 in non-health professions, and 10 not currently in the labour force. India (29%), the UK (16%), and South Africa (10%) were the primary source countries for informants, followed by Malaysia, the Philippines and South Korea, with a scattering from a broad range of other countries. General Skilled Migration PA s dominated migrants with medical qualifications responding to the CSAM survey at this time (720 informants compared to 80 family category migrants). Medical migrants selected in the GSM category reported very strong employment rates working in health, presumably medicine, with negligible numbers unemployed or not in the labour force at this time. Family category migrants (all fields) reported dramatically higher unemployment and NILF rates the data not permitting definition of the proportion of these who were medically qualified. (See Table 18.) Table 18: Employment Outcomes and Profession of Primary Applicant by Field for Health Professionals Selected by Skilled Compared to Family Categories (CSAM ) No Qualification/ Employment Outcomes Health Field All Other Fields Qualification Not Stated Total & Profession Skilled Family Total Skilled Family Total Skilled Family Total Skilled Family Total No. No. No. No. No. No. No. No. No. No. No. No. Employed Health professions Medicine Nursing & Midwifery 1, , , ,320 Dentistry Pharmacy Physiotherapy Other Allied Health 1, , , ,540 All Health Professions Total 4, , , ,200 All Other professions ,060 25,620 10,480 36,100 3,030 4,600 7,630 29,140 15,650 44,790 Unemployed ,480 3,790 5, ,470 2,700 1,760 6,660 8,410 Not working/nilf(a) ,390 4,570 5, ,960 6,620 2,210 11,180 13,380 Total 4,840 2,120 6,960 28,740 18,920 47,660 4,110 13,070 17,180 37,690 34,110 71,790 (a) NILF - Not in the Labour Force Note 1: Figures have been rounded to the nearest 10 Source: Analysis of unpublished CSAM data provided by the Department of Immigration and Citizenship to Health Workforce Australia (2011). 70

72 In terms of salaries the CSAM showed the following outcomes: Medicine: Annual wages reported for GSM doctors 18 months post-migration 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. Further analysis of the CSAM is provided in Section 7. Employment Outcomes for Former International Students Qualified in Australia A further important database exists, to be reported in detail in Section 7. As stated earlier, former international students have emerged as a major health workforce resource for Australia. When analysis of Australia s Graduate Destination Survey (GDS) from 2006 to 2010 was undertaken it demonstrated phenomenally successful employment outcomes for former international students, four months following course completion. In brief: Substantial numbers responded to the survey, including 675 qualified in medicine. By % resident in Australia were available for work. Virtually all were employed in medicine full-time (98.9%), compared to 99.7% of domestic medical graduates then available. Results were similarly strong across all 5 survey years. For example in % of former students resident in Australia were in the workforce. 96.9% had secured fulltime medical work, while 3% continued to seek employment. In terms of salaries, negligible difference was found compared to Australia-born medical graduates (just $2,000-$3,000 per annum). 2.4 Nurses and Midwives Recent Nurse Migration Recent decades as we have seen have coincided with rapid diversification of nurse migration. Within Australia there has been rising dependence on internationally educated nurses (IEN s), to compensate for chronic nurse shortages, due to the continued exodus of Australian nurses overseas or to emerging opportunities in other professions. Between and ,544 IEN s entered Australia on either a permanent or a temporary basis, counter-balancing 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) 135. The period to saw an additional 11,757 permanent or long-term IEN arrivals, with nursing a constant priority in Australia s skilled migration program. This pattern of reliance on IEN s was a phenomenon simultaneously occurring in New Zealand, the UK, the US, Canada and the Middle East the globalisation of nursing reflecting escalating OECD demand, in addition to the growing agency of women in skilled migration (their desire for improved quality of life, enhanced professional opportunity and remuneration, and adventure) 136. Between 2001 and ,680 degree-qualified nurses migrated to Australia, compared to 3,100 from (across all immigration categories). The top 5 sources at this time were the 71

73 UK/Ireland (2,081), the Philippines (1,009), India (455), Japan/South Korea (383) and China (356). Employment Outcomes for Recently Arrived Migrant Nurses (All Categories) Overall 63% secured employment in nursing within 5 years, reflecting Australia s evolution of bridging programs and sustained workforce demand 137. In line with medical migrants outcomes, however birth country/region of origin were major issues. Nurses from Singapore were immediately acceptable 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%) also fared well, but results were worse for those migrating from Central/South America (31%) and North Africa/ Middle East (33%). (See Table 19.) Table 19: Employment Status of Australia/New Zealand Degree-Qualified Nurses, Compared to Overseas-Born Nurse Arrivals (2006 Census) Arrival Date Employed Other Percentage Number Birth Own Other Other Sub- (b) Country Prof Prof Work Total Unemp NLF Australia/New Zealand ,704 Arrived UK/Eire (Ireland) Northern Europe Western Europe South Eastern Europe Eastern Europe Viet Nam Indonesia Malaysia Philippines Singapore China (Not SARs/Taiwan) Hong Kong/Macau Japan/South Korea Other Southern and Central Asia India Sri Lanka/Bangladesh Canada/USA Central/South America Other Sub-Sahara Africa South Africa North Africa/Middle East Other Total migrants Notes: Excludes those for whom birthplace or year of arrival is unknown. a = Many of the cells are based on very small numbers, therefore the results should be regarded as indicative only. Empty cells are where there are insufficient cases for reliable reporting and issues of confidentiality. E.g. there were just 12 degree-qua b = Due to missing data, imputation and aggregation, numbers may not add up to 100%. Source: Analysis of 2006 Australian Census data, L Hawthorne (2008), Migration and Education: Quality Assurance and Mutual Recognition of Qualifications Australia Report, UNESCO, Paris. Nurse migration has continued to grow rapidly since. From to ,400 registered nurses were selected as GSM PA s, rising to 7,676 once partners are included. Substantial additional numbers reached Australia through family and refugee categories. Such permanent flows were dwarfed however by the scale of 457 visa arrivals. In ,270 temporary registered nurses were selected, rising to 3,850 in In all 14,950 temporary registered nurses were sponsored to Australia from to , in addition to registered mental 72

74 health nurses and midwives. As we have seen, these nurses went to highly dispersed sites: the major states of sponsorship in being Victoria (1,010), Queensland (780) and Western Australia (750). (See Table 12.) As is the case with medicine, the most recent data for show significant growth in permanent resident GSM migration but a drop in nurses/midwives sponsored on a temporary resident basis, as follows: GSM: 1, nursing/midwifery PA arrivals (compared to 1,360 in and 1,470 in ) 457 Long-Stay Business Visa: 2, nursing/midwifery arrivals (compared to 4,070 in and 2,660 in ) By a third were selected via the study-migration pathway. Employment Outcomes for Former International Students Qualified in Australia Analysis of Australia s Graduate Destination Survey from 2006 to 2010 demonstrates again highly successful employment outcomes for former international students, four months post course completion, though their results were not as exceptional as in medicine. In brief: 2,227 former international students qualified in nursing responded to the GDS survey (compared to 15,644 domestic graduates). By % of former international students still resident in Australia were available for work. Two-thirds (69.6%) were already employed in nursing full-time, with an additional 20.8% in part-time nursing employment. (This compared to 93.4% and 4.8% of domestic graduates then available for employment.) Results were strong across all 5 survey years, with outcomes in 2010 the most modest (an Australia-wide trend following the global financial crisis). In 2006, for instance, 76.8% of former students resident in Australia wanted work. 91.5% already had fulltime nursing employment, while an additional 6.6% had secured part-time nursing work. A further 7% were undertaking full-time study, with just 1% still seeking work. In terms of salaries, comparable or higher salaries were achieved by former international students at 4 months than by Australia-born graduates (perhaps reflecting the number of hours sought). 2.5 Dentists Recent Dentist Migration and Employment Outcomes (All Categories) Increasing migration is also evident in relation to dentistry, where arrivals have doubled in recent years (rising from 540 in to 1,125 in ). India has been the major source (320 arrivals, compared with 128 from North Africa/Middle East, 125 from the UK/Ireland, and 88 from the Philippines and 78 from Central/South America). As with nursing and medicine however, marked variations in terms of access to dental employment prevailed. South Africa qualified dentists moved seamlessly into work (89%), followed by dentists from Malaysia (84% - many former students qualified in Australia), the UK/Ireland (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 work), China (21%) and the Philippines (7%). 73

75 This represents a serious issue, given the prominence of these source countries in recent dental workforce migration. According to the Australian Dental Council (ADC), Indian migration has recently surged a supply-driven process, addressing public sector employment demand in dental areas of need. In 2006 however large numbers were categorised as not in the labour force, in particular dentists derived from India (44%), Other Southern and Central Asia (71%), and China (46%). (See Table 20.) Table 20: Employment Status of Australia/New Zealand Degree-Qualified Dentists, Compared to Overseas-Born Dentist Arrivals (2006 Census) Arrival Date Employed Other Percentage Number Birth Own Other Other Sub- Country Prof Prof Work Total Unemp NLF Australia/New Zealand ,759 Arrived UK/Eire (Ireland) Northern Europe Western Europe South Eastern Europe Poland Eastern Europe, remainder Viet Nam Indonesia Malaysia Philippines Singapore South-East Asia, remainder 17 China (Not SARs/Taiwan) Hong Kong/Macau Japan/South Korea North-East Asia, remainder India Sri Lanka/Bangladesh Other Southern and Central Asia Canada USA Central/South America South Africa Other Sub-Sahara Africa North Africa/Middle East Other Total migrants Source: 2006 Census (Australia). Notes: Excludes a = Many those of the for whom birthplace or year of arrival is unknown. cells are based on very small numbers, therefore b = Due to missing data, imputation and aggregation, numbers may not add up to 100%. Source: Analysis of 2006 Australian Census data, L Hawthorne (2008), Migration and Education: Quality Assurance and Mutual Recognition of Qualifications Australia Report, UNESCO, Paris. Employment Outcomes for Former International Students The most recent trends in in dental workforce migration via the GSM and the 457 visa categories are as follows, with growing numbers as in medicine and nursing selected onshore: GSM: 180 dentist arrivals (compared to 130 in and 70 in ) 457 Long-Stay Business Visa: 150 dental arrivals (compared to 160 in and 90 in ) 74

76 Analysis of Australia s Graduate Destination Survey from 2006 to 2010 demonstrates exceptionally successful employment outcomes again for former international students, four months following course completion. The results are as strong as reported for medicine. In brief: 98 former international students qualified in dentistry responded to the GDS survey (compared to 860 domestic students). By % of international students still resident in Australia were available for work. Of these 93.8% were employed as dentists full-time, while an additional 6.3% were seeking employment. (This compared to 93.6% and 1.6% of domestic graduates then available for full-time work.) Results were strong across all 5 survey years, with outcomes in 2010 relatively modest. For example in % of former students in the workforce in Australia were employed in dentistry full-time, compared to 95% in 2008 and 94% in In terms of salaries, marginally lower, comparable or higher salaries were achieved at 4 months than by Australia-born dental graduates (depending on the year). For example in 2008 former international students averaged $95,000 commencing salaries (16 respondents), compared to $80,000 for domestic graduates (596 domestic respondents). This dropped to $76,696 in 2010 compared to $80, Pharmacists Recent Pharmacy Migration and Salary Outcomes By 2006, there were 4,962 degree-qualified migrant pharmacists resident in Australia - 8% of the total pharmacy workforce, including 749 who had arrived in the previous 5 years. Despite this, limited public data exist on migrants employment or registration outcomes. From to an additional 2,080 pharmacists were selected as GSM primary applicants, rising from 250 in to 560 in From to pharmacists also arrived under the temporary 457 visa category. According to the Australian Pharmacy Council (APC) Annual Report, a substantial number of eligibility assessments for General Skilled Migration were undertaken that year. Twenty-eight percent of applications originated in Australia (most likely from former international students who wished to stay). Primary offshore sources of applicants were from candidates located in Egypt (26%), India, (12%), the Philippines (7%), South Africa (6%), Pakistan (4%) and Bangladesh (2%). By the APC s Competency Assessment of Overseas Pharmacists (CAOP) of overseas trained applicants was being offered in London, Auckland and Australian capital cities four times per year, with applicants trained in Egypt, India and the Philippines predominating 138. Candidates attempting the APC s Stage 11 exams (on first or repeat attempts, following successful completion of the Stage 1 and National Forensics, Ethics and Calculations [NFEC] exams plus supervised practice), were similarly diverse. The majority were derived from Egypt (an extraordinary 52%), followed by India (17%), the Philippines (6%), Zimbabwe (4%), Pakistan, South Africa and Nigeria (3% each), and Singapore and Iraq (2% each). In May 2010 however, it is important to note, pharmacists were removed from Australia s new Skilled Occupation List a move anticipated to substantially reduce future GSM arrivals. An exception is the state/territory sponsored lists, which currently facilitate the entry of hospital, industrial and retail pharmacists. 75

77 Graduate Destination Survey data were not sourced and analysed in relation to former international pharmacy students remaining to work in Australia. 2.7 Rehabilitation Professionals The migration level of physiotherapists to Australia has been modest to date - just 2,409 degreequalified overseas-born physiotherapists resident in Australia by 2006, including 469 arrivals in the period. An additional 394 recent migrants were admitted at this time with diploma level qualifications (unlikely to secure registration at the professional level). From to an additional 550 physiotherapists were selected as GSM primary applicants, slightly rising from 110 in to 130 in (noting substantial annual fluctuations). From to a further 420 physiotherapists were sponsored under the temporary 457 visa category. According to the Australian Physiotherapy Council (APC) Chief Executive Officer, Margaret Grant, 2010 was an abnormal year, with potential offshore applicants aware of forthcoming assessment and skilled migration policy changes, resulting in the lowest number of applications in the second half of 2009 and the first half of 2010 of the previous 6 years. 134 positive skilled assessments were finally issued, with 5 current pathways to achieve full registration for practice. As is the case with medicine, nursing and dentistry, large numbers of migrant physiotherapists do not proceed with the full APC assessment process, noting final approvals are not necessarily indicative of their failure to pass. Grant states: If people simply look at the (completion outcomes) it can look like a very low number of people who (have) the initial assessment go on to finish. But that is not an accurate interpretation of the data We have a high level of (applicants whose) circumstances change. They (may) have applied to America, Canada, Australia and England, and they just accept whichever one comes first or they realised for Australia they can actually apply through New Zealand, so they continue with that. I am aware that from July 2010 the government is collecting data on withdrawals and (applicants) now actually fill in an application of withdrawal and provide the reasons. Employment Outcomes for Former International Students Analysis of Australia s Graduate Destination Survey from 2006 to 2010 demonstrates very positive employment outcomes for former international students, four months following course completion. In brief: 141 former international students qualified in physiotherapy responded to the GDS survey (compared to 2,644 domestic students). By % of former international students still resident in Australia were available for work. Two-thirds (69.2%) were employed in physiotherapy full-time, while an additional 19.2% were working in the field part-time. (This compared to 91.3% and 6.7% of domestic graduates then available for full-time employment.) Results were strong across all 5 survey years, with outcomes in 2010 again relatively modest (reflecting the global financial crisis). For example in % of international students resident in Australia were in the physiotherapy workforce. 100% had found employment in physiotherapy full-time. Salaries were virtually identical at 4 months to those achieved by Australia-born physiotherapy graduates (any year). For example in 2006 former international 76

78 students averaged $43,250 commencing salaries compared to $43,000 for domestic graduates. This rose to $47,825 in 2010 compared to $47, The Role of AHPRA in Relation to Migrant Health Professionals By definition these outcomes were achieved by migrant health professionals trained in Australia. Their salaries affirm the success of onshore primary applicants (typically former international students) compared to health professionals unscreened in advance for human capital attributes. Health professionals admitted via the General Skilled Migration (permanent) and 457 visa (temporary) categories also fare well. As demonstrated by the 2006 Census analysis in relation to medicine, nursing and dentistry, substantial numbers of other migrant professionals face severe displacement in their first 5 years, most notably those selected as partners or across the family and humanitarian categories. (Identical or worse patterns prevail in Canada, the US, the UK, continental Europe and New Zealand.) The aim of the following sections is to identify the key groups at risk and why critical issues from a health workforce planning perspective. In terms of accreditation it is important to note that in March 2008 the Council of Australian Governments signed an Intergovernmental Agreement on the health workforce, to create for the first time a single national registration and accreditation system for the ten key health professions. Established in July 2010, a key aim of the Australian Health Practitioner Agency (AHPRA) is to ensure consistency of standards, including that a professional who has been banned from practising in one place is unable to practise elsewhere in Australia 139. From July 2010, in terms of access to practice, AHPRA has had a critical national role to play. As agreed by the Australian Health Workforce Ministerial Council, ten (2010) and ultimately twelve (2012) National Boards will be established, charged with establishing registration standards to cover: criminal history screening, English language requirements, continuing professional development, recency of practice and professional indemnity insurance arrangements Specialist registration standards, including approved lists of specialties and protected specialist titles, for medical specialists, dental specialists, and podiatric surgeons (a) series of board-specific area of practice endorsements for suitably qualified dentists (conscious sedation), endorsement of nurse practitioners, and endorsement of seven areas of practice for suitably qualified psychologists Standards for scheduled medicine endorsements for suitably qualified and registered optometrists, podiatrists, and rural and isolated practice registered nurses In approving the registration standards, Ministers noted that the respective National Boards will monitor their application to health practitioners under the national scheme., and be mindful of the need to review the approved registration standards every 3 years of earlier, should that prove necessary in the interests of the provision of professional health services to all Australians 140. Within this transforming national regulatory environment, key barriers for migrant health professionals are next examined. 77

79 Section 3: The Impact of English Testing on Migrant Health Professionals 3.1 English Testing Requirements The Significance of English The first hurdle confronting migrant health professionals is demonstration of advanced English language ability - a key requirement for safe practice. Since 2006 this has applied to temporary as well as permanent resident arrivals, noting pass rates are mandatory for General Skilled Migration selection. The significance of language testing is confirmed by Australia s recent skilled migration sources. Table 21 ranks the top 20 source countries for the GSM program from to , while Table 22 ranks sources for the 457 visa sponsored program from to Table 21: Top 20 Source Countries for Migrant Health Professionals to Australia, Selected through the General Skilled Migration Program, Primary Applicants ( to ) Rank Citizenship Country Total No. No. No. No. No. Number 1 United Kingdom India Malaysia China, Peoples Republic of Egypt, Arab Republic of South Africa, Republic of Philippines Korea, Republic of Singapore Irish Republic Canada HKSAR of the PRC Zimbabwe Sri Lanka United States of America Iran Burma (Myanmar) Germany, Federal Rep. Of Nepal Japan Other countries Total Source: Department of Immigration and Citizenship, 2011 (BE ) Note 1: Data is for principal applicants only Note 2: Figures have been rounded to the nearest 10 Note 3: Health professionals includes ASCO Minor Group 231, 232, 238, 239 and 349 Source: Immigration flows data provided by the Department of Immigration and Citizenship 78

80 Table 22: Top 20 Source Countries for Migrant Health Professionals to Australia, Selected through the 457 Visa Program, Primary Applicants ( to ) Total Rank Citizenship Country No. No. No. No. No. Number 1 United Kingdom India Ireland, Republic of Malaysia China, Peoples Republic of Philippines South Africa Canada United States of America Sri Lanka Zimbabwe Pakistan Singapore Iran Germany, Fed Republic of Korea, South Burma Nepal Nigeria Japan Other Countries Total Source: Department of Immigration and Citizenship, 2011 (BE ) Note 1: Figures rounded to the nearest 10 Note 2: Health professionals includes ASCO Minor Group 231, 232, 238, 239 and 349 Source: Immigration flows data provided by the Department of Immigration and Citizenship As established in Section 1, between and ,640 temporary 457 visa applicants were selected from the major English speaking background countries by employers (45% of the total), in a context where sponsors demonstrated a strong preference for native or near native ability in English. This compared with a total of 6,900 ESB health professionals selected as primary applicants through the GSM program from and (43%, noting that arrivals by country are shown in Table 19 for direct comparison). Large numbers of additional health professionals arrived unfiltered as skilled migrants dependents, or through the family and humanitarian categories. The scale of non-english speaking background migration matters. 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 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 job

81 In 2009 a Department of Employment Education and Workplace Relations (DEEWR) commissioned study identified level of spoken English as the key predictor of Australian employment for skilled migrants at both 6 and 18 months, for onshore as well as offshore Independent migrants. At 18 months, onshore skilled migrants who spoke English very well or for whom it was the first language were 3.7 times more likely to be employed in Australia compared to those with poor English 142. Within this context, externally validated pre-migration English assessment has become a key eligibility hurdle for GSM migration (with stakes intensified from 2010). English testing has also become essential to migrant health professionals securing limited or general registration in the medical and allied health fields, whether arriving on a permanent or temporary basis. The impact of mandatory language testing is thus profound, as demonstrated first below in relation to medicine and nursing. Migrant health professionals can elect to take either the International English Language Testing System (IELTS) or the Occupational English Test (OET) exams, except in dentistry where the OET until recently was mandatory. (Both tests are now accepted.) Regrettably, IELTS results are unavailable for analysis. 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 as the drawbridge to vocational registration. 3.2 The Impact of English Language Testing in the 1990s The Occupational English Test Australia introduced the Occupational English Test for migrant doctors and allied health professionals from the late 1980s - a field-specific measure of English language ability designed to precede the subsequent testing of medical knowledge 143. Prior to this there had been no systematic guidance as to the levels of English proficiency required in individual occupations, including differing levels of fluency or specialist occupational terminology. Nor had appropriate specialist tests of English been devised. As early as 1988 the Committee to Advise on Australia s Immigration Policies had considered this problematic, concluding that: English should not be a make or break factor when there are other factors on which the applicant scores well enough to get into the (migration applicant) pool. But it must be included in any selection system which recognises the importance of skills... and where there are two applicants who score equally on other factors, English must be decisive... In assessing English proficiency, the level of English required by the immigrant to carry out the duties of his or her occupation in Australia should be the primary consideration 144. In 1990 Ralph Blacket, Chairman of the Australian Medical Council s Examination Committee, had stated:...all English speaking developed countries take the view that foreign medical graduates who choose to emigrate must demonstrate in objective testing a good level of proficiency in English as well as the level of professional competence expected of graduates in their chosen country 145. Occupational English Test Impacts: 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 80

82 at least once. Speaking, listening, reading and writing skills were separately scored, in healthrelated contexts. An analysis of results found major impacts from this language testing by the mid 1990s. The OET prevented or significantly delayed 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. Differential pass rates were evident by language group, with the best rates achieved by speakers of Indian languages (84%), Filipino languages (83%) and Arabic (82%), compared to lower pass rates for speakers of non-arabic Middle Eastern languages (71%), Chinese (66%) and Vietnamese (64%). The impact of mandatory 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 just 32% of nurses passed the OET 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 again evident, with pass rates as follows for the top 5 applicant source countries: 35% for nurses from the former Yugoslavia, 41% from the Philippines, 50% from Hong Kong, 55% from India and 70% from Fiji. (See Table 23.) Table 23: Occupational English Test Pass Rates by Region of Origin, Field of Training ( ) Region of Origin Medicine Nursing % of all Cand. % Pass Rate % of all Cand. % Pass Rate Oceania North Europe South Asia Former Yugoslav Republics South & West Europe E Europe Former USSR Middle East & North Africa South America Africa (excl. North Africa) South East Asia Central America & Caribbean North East Asia Total number 2, , Source: Adapted from Hawthorne, L & Toth, J (1996), The Impact of Language Testing on the Registration of Immigrant Doctors, People & Place, Vol 4 No 3, Monash University, Melbourne In July 1996, for instance, the level of Filipino demand for migration was so intense that a special administration of the OET was held in Manila for 110 nurses (among the 350 Filipino candidates attempting the OET that year). According to an Australian officer based in Manila at that time, (M)any of these people we knew were going to fail - had no chance in hell of passing!.. But we can t counsel them to say you re going to fail, because we don t do the assessment. We knew the agents were giving the wrong advice and taking money off them... The drain of resources was becoming quite difficult. We were having special English testing, and staff dedicated to processing it. We weren t running the tests - we were coordinating them, and... getting all the information to them, passing it down to the testing agency. The frustrating thing was the poor outcome - and you knew what the outcome would be!... (T)hey react (to the news of) failing the English test like there s no tomorrow!... Candidates don t readily accept that they ve failed their English test. They 81

83 often want to re-sit it or want a refund. You have to explain to them that they ve actually paid for a service, not an outcome 146. A study of 1,000 migrant nurses conducted in the mid 1990s demonstrated the OET to be the most powerful employment barrier encountered by overseas qualified nurses in Australia at that time. A significant number of respondents reported enrolling in a range of English programs. Many NESB nurses described the turmoil of their first labour market rejection, including its link to English competence, such as the following Filipino informant: (The Director of Nursing didn t state what was expected.) The first thing she did was (say) Look let s say you re in a situation where you re in the ward and then you answer the phone (she pretended to call). You pick up the phone, and then write down what I tell you! So that s what she did, first thing. So I was so scared and instead of writing down hypertension I wrote down hypotension and (later) she said Well, you re just above the pass mark, but she asked me (about) those mistakes I did, (like) when do you say a patient (has) hyperglycaemic and hypoglycaemic signs and symptoms (I)t was a terrible interview, then she was saying, Look, can you come back in three months time because you have to acclimatise yourself! 147 Once passed, migrant nurses could proceed immediately to professional registration a relatively simple procedure by the late 1990s involving completion of the three month competency-based bridging courses mandated for 71% of NESB nurses compared to just 3 per cent of English speaking background nurses. In the state of Victoria, throughout the 1990s, pass rates of 90-95% would be typical for course participants. In NSW (where entry-level English language ability was more flexibly assessed) pass rates would vary from 55-71%, with the growing participation of Filipino and Fijian-trained nurses reportedly dragging averages down. In the context of sustained Australian labour market demand however, once migrant nurses had passed the OET and secured professional recognition the majority passed seamlessly into professional employment. 3.3 The Impact of English Language Testing from Increasing English Language Requirements 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 (with Good User considered the lowest acceptable level for safe practice) for registration. 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 successive tests. By 2010, by contrast, all four modules had to be passed in a single setting as we shall see a far more challenging hurdle. Such changes in Australian policy 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). For example one Indian doctor with 22 years experience as a General Practitioner noted: The NSW Medical Board changed its English proficiency requirement policy in early The policy states that all AMC graduates who are seeking a medical board registration must provide English proficiency examination results mot more than two years old at the time of internship (one year supervised training). I provided my English 82

84 proficiency examination results which was a mandatory requirement of AMC before appearing in their MCQ theory and Clinical practical examinations. I completed all my exams in June 2007 and the new English policy was imposed from 1 st July In 2007, the Medical Boards throughout Australia including NSW granted hundreds of registrations to Overseas Trained Doctors on the basis of their English proficiency but not AMC graduation. I approached several politicians. All these politicians have favoured my registration request to the board but the board has refused all my requests (Dr. Mohammed Hanif Anarwala, Submission No. 18, 24 January 2011) 148. Within the above context, how significant a workforce barrier is English language testing for migrant health professionals from non-english speaking background countries? In brief, the OET (along with comparable IELTS levels) constitutes a very formidable challenge. The Impact of the OET on Migrant Health Professionals: OET examination data were secured and analysed from to assess the test s impact the first such in-depth analysis 149. Within the period studied, 24,683 migrant candidates had attempted one or more modules of the test, with multiple attempts the norm 5. 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 (This decline reflects the higher English standards now required, as well as the completion of backlog testing for temporary migrant health professionals.) Two important trends are illustrated by Table 24: the rapid recent growth in candidate numbers, particularly in nursing (rising from 696 in 2005 to 1,917 in 2010) and dentistry (rising from 195 in 2005 to 1,293 in 2010), and candidates high failure rate on individual tests (necessitating repeat sittings). From the great majority of OET candidates made more than one attempt 1.5 in 2010 being the norm for medicine and 1.4 for dentistry (where the OET was the sole acceptable test). Significant numbers of candidates were likely to have become discouraged without passing the test during this period. The scale of attempts rose to 1.6 for nursing and pharmacy candidates, and 1.7 for physiotherapy. The length of time required to pass the OET could be significant, in a context where the test was administered only seven times per year, with candidates required to pass all four speaking, listening, reading and writing sub-tests in a single sitting by The following administrative points are worth noting: The OET currently tests 12 professions: Dentistry, dietetics, medicine, nursing, occupational therapy, optometry, pharmacy, podiatry, physiotherapy, radiography, speech pathology and veterinary science. It is administered in 19 countries, in addition to Australia (Brazil, Canada, Egypt, Germany, Hong Kong SAR, India, Iran, Japan, Malaysia, New Zealand, Pakistan, Philippines, Saudi Arabia, Singapore, South Africa, Sri Lanka, United Arab Emirates, United Kingdom, and the USA). Migrant health professionals have been exempt from English language testing when tertiary-qualified in the medium of English in the following countries: Australia (ie former international students), Canada, New Zealand, the Republic of Ireland, South Africa, the United Kingdom and the USA. 5 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. 83

85 It is important to note however that there are no automatic exemptions by country for migrant health professionals qualified in nursing the reason until mid-2011 (for example) why there were significant numbers of OET South African candidates 150. Table 24: Occupational English Test Attempts by Key Field ( ) Candidate Field No. of Passes No. of Failed Sittings Total Sittings No. of %Pass %Fail %Pass Candidates (Sittings) (Sittings) (Candidates) Medicine % 71.5% 43.2% 1.52 Medicine % 62.3% 53.4% 1.42 Nursing % 88.1% 19.4% 1.63 Nursing % 86.2% 19.7% 1.43 Dentistry % 65.6% 47.1% 1.37 Dentistry % 71.3% 40.0% 1.39 Physiotherapy % 80.5% 33.9% 1.74 Physiotherapy % 76.2% 38.5% 1.62 Pharmacy % 82.3% 27.7% 1.56 Pharmacy % 71.4% 39.1% 1.37 Other allied health % 78.9% 31.7% 1.51 Other allied health % 70.5% 46.4% 1.57 Total % 78.1% 33.5% 1.53 Total % 73.7% 37.3% 1.42 Grand Total % 77.0% 34.5% 1.50 Average No. of Sittings Source: Analysis of Occupational English Test results by Anna To, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne (data supplied by the Centre for Adult Education (Victoria), the test administrator, April 2011). *This figure equates to both the number of candidates and the number of sittings as each person only needs to pass once. OET Outcomes by Number of Attempts, Field, Test Location and Source Country Overall OET pass rates varied significantly by qualification field, with a 37% average pass rate in 2005 (when passes could be earned by taking sub-tests across sequential sittings) dropping to just 34% in In 2010, for example in medicine, 1,841 sittings were attempted by 1,214 candidates, with 524 passing. Of all tests attempted by dental candidates, 34% were passed in one sitting, compared to 29% of test sittings passed by medical candidates 6. The challenge of passing all four OET components in a single sitting is highlighted by figures which show that higher levels of success are associated with individual sub-tests. 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 43% by nurses. This translated however 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 greater barrier. Place of application also significantly influences language testing outcomes candidates sitting the test in Australia having access to preparatory training, and by definition immersed in an English speaking society. 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 6 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. 84

86 for medically qualified migrants from Forty-seven percent of candidates passed the OET for instance 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). The highest OET failure rates in terms of sittings attempted 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%. (See Table 25.) Table 25: Occupational English Test Outcomes by Country of Training ( ) No. of No. of Failed Total No. of %Pass %Fail %Pass Average no. Country Of Training Passes* Sittings Sittings Candidates (Sittings) (Sittings) (Candidates) of Sittings South Africa % 45.5% 65.6% 1.20 South Africa % 70.0% 42.9% 1.43 United Kingdom % 57.5% 53.4% 1.26 United Kingdom % 0.0% 100.0% 1.00 Jordan % 61.5% 46.5% 1.21 Jordan % 62.5% 42.9% 1.14 Pakistan % 68.7% 44.1% 1.41 Pakistan % 60.6% 53.1% 1.35 Iraq % 71.9% 43.2% 1.54 Iraq % 69.5% 46.2% 1.51 India % 69.8% 43.2% 1.43 India % 78.8% 30.9% 1.45 Myanmar (Burma) % 73.8% 42.9% 1.64 Myanmar (Burma) % 70.0% 35.3% 1.18 Bangladesh % 73.3% 42.6% 1.59 Bangladesh % 68.5% 45.6% 1.44 Sri Lanka % 75.1% 40.4% 1.63 Sri Lanka % 60.9% 52.9% 1.35 China % 75.7% 38.9% 1.60 China % 81.9% 25.7% 1.42 Iran % 76.9% 32.8% 1.42 Iran % 68.1% 44.1% 1.38 Egypt % 80.9% 28.6% 1.50 Egypt % 62.9% 48.7% 1.31 Philippines % 86.0% 24.2% 1.74 Philippines % 73.2% 36.7% 1.37 Saudi Arabia % 87.0% 19.1% 1.47 Saudi Arabia % 100.0% 0.0% 1.25 Japan % 91.3% 14.6% 1.67 Japan % 81.3% 25.0% 1.33 Other Countries % 82.6% 27.3% 1.57 Other Countries % 73.6% 38.5% 1.46 Total % 78.1% 33.5% 1.53 Total % 73.7% 37.3% 1.42 Grand Total % 77.0% 34.5% 1.50 Source: Analysis of Occupational English Test results by Anna To, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne (data supplied by the Centre for Adult Education (Victoria), the test administrator, April 2011). *This figure equates to both the number of candidates and the number of sittings as each person only needs to pass once. 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 85

87 proved challenging. Chinese candidates were the sole non-english speaking background group to have improved their OET outcomes in 2010 compared to 2005 reflecting the markedly greater exposure to English now characteristic of China. Overall, as shown in the right hand column of Table 25, the following country of origin groups had a descending order of success by 2010 (after re-sitting as required), noting results for Filipino (24%) and Egyptian (29%) candidates remained very poor: South Africa: 66%, Pakistan: 44%, Iraq: 43%, Bangladesh:43%, India: 43%, Sri Lanka: 40% and China: 39%. The significance of these outcomes is demonstrated by the 2006 Census analysis. As previously noted 5,094 migrant health professionals from India were resident in Australia at this time, compared to 4,638 from the Philippines, and 3,200 from China. Large numbers were recent arrivals, including 2,063 from India, 989 from the Philippines, and 651 from China (the Census by definition capturing all immigration categories). The impact of language testing on many migrants was likely to be profound. 3.4 English Language Testing 2011 Policy Developments Points Test Review Changed Selection Requirements It is important to note in relation to English language standards the latest Australian policy developments. In 2010 the Department of Immigration and Citizenship undertook a thorough review of the General Skilled Migration Points Test, with marked consequences. From July points (rather than 120) are required for successful selection (all fields). Key changes include: English: No points will be allocated for meeting Australia s threshold English language requirement of IELTS 6 or equivalent. However 20 points will be awarded to applicants with IELTS 8 (near native speaker level) and 10 points to PA s with IELTS 7 with English reinforced as a key determinant of selection. Place and level of qualification: Minimal advantage will now flow from possession of Australian qualifications (just 5 bonus points). Instead, level of qualification will be rewarded - 20 points for a PhD, 15 for a Bachelor or Masters degree, and 10 for a vocational qualification (regardless of study location). Occupation: In marked contrast to recent practice, no points will be allocated to applicants with an occupation in demand (a qualification on the Skilled Occupation List introduced in July 2010 representing a hurdle rather than a points-rewarded requirement). Age: Eligibility for skilled migration will be extended to PA s aged up to 49 years, with the greatest points allocated to young and experienced workers (25-32 years) rather than new graduates (as previously the case) or older applicants. Experience: Bonus points will now be provided for both Australian and overseas experience, with only a slight premium for recent Australian employment. These points test changes reflect Australian employer and regulatory body preferences. In future the GSM will markedly favour the selection of older native English speakers, qualified with Bachelor or higher tertiary degrees. The government s aims in this policy transition are clear to deliver the best and brightest skilled migrants by emphasising high level qualifications, better English language levels and extensive skilled work experience

88 June 2011 Developments Instrument Diversification Additional recent policy developments have occurred in relation to English language testing. In June 2011 DIAC announced that the following tests would in future be accepted for international students enrolled in Australian courses. This move is certain to influence GSM and 457 visa selection (and potentially regulatory body requirements) given the scale of international students qualifying onshore 152 : TOEFL (Test of English as a Foreign Language) Pearson Test of Academic English Cambridge English Advanced Exam The IELTS test, which long held an Australian monopoly on language testing for skilled migration (along with the OET) has also recently come under sharp attack in ABC Radio s Background Briefing program in relation to: Fitness for purpose The incidence of fraud Instability of results In 2006, Australia s most detailed review of the GSM program in 20 years had raised a number of these issues, stating: Integrity in language testing is vital to assuring score accuracy, with the bulk of test-taking to date occurring offshore. In relation to this it should be noted that Australia and other immigrant-receiving countries have experienced significant problems related to candidate substitution and security violations in recent years. In China, the world s largest IELTS centre until overtaken by India (87,000 administrations per year in 26 test centres operating at capacity), the following measures have recently been required to address this issue: Encrypted online registration (to mask identity information); Use of an electronic ID verification system; Photo enrolment on the actual test day to minimise substitution; Maintenance of an imposter database in Beijing (made available to all test supervisors in order to aid recognition); Scanning of candidate photos taken the day of administration against the imposter database and all other photos of candidates; Training of Embassy and IELTS staff in facial recognition techniques; Provision of public notice on these procedures to all candidates; and Appointment of a full-time IELTS Security Manager. With the global growth of fraud, the Panel strongly endorses such measures as essential to ensure accurate point of entry assessment. A second operational issue concerns the potential value of offering the revised Test of English as a Foreign Language (TOEFL) test as an alternative to IELTS - an option we understand (the Department of Immigration and Multicultural Affairs) to be aware of. IELTS scores are somewhat unstable: a student having a 40% chance of securing a different result on re-testing, based on a.77 published reliability rate for speaking and writing. According to a prominent academic consulted, the latest TOEFL test has a number of advantages relative to IELTS, being: Internet based; Associated with greater stability of scores (a.9 correlation); Simultaneous administration in secure test centres around the world, with greater integrity than IELTS at somewhat lower costs; and 87

89 A capacity to elicit superior information concerning test takers capacity to communicate in an academic setting. The Panel considers there to be merit in accepting TOEFL as an alternative approved measure of English language ability to IELTS 153. It should be noted that IELTS had initially been developed for one purpose only in England in the 1980s so that universities could determine whether international students had good enough English to cope with academic demands. According to the ABC s analysis: IELTS is a high stakes test. 6,000 institutions worldwide rely on it, including universities, professional bodies and migration authorities. And in 2010 alone, IELTS recorded a peak of 1.5 million tests being taken around the world. Over the years, Sydney-based migration agent Jonathan Granger has consulted dozens of people about their experiences with the test. He says that results often vary, each time they take the test. He s tried to understand why this is happening. (Jonathan Granger:) We ve looked at the client and said, Well, how did you get a 6.5 in the last three times you sat the test, (when you ve previously) scored 7.5 or 8. Then suddenly on this one test you re above 7 s on everything else and you ve dropped down to 6.5?... So there s areas of concern that you can find countless examples of that when you look at the number of students who have been tested (and scored) all over the place 154. In the context of growing Australian debate on English language standards, and the high life stakes associated with tests, the Australian Health Practitioner Regulation Agency will review pre-registration requirements, including global competitor practices in relation to professional registration. 88

90 Section 4: Access to Vocational Registration - Medicine 4.1 Pre and Post-Migration Screening The Challenge As demonstrated in the previous section, English language testing constitutes a formidable hurdle for migrant health professionals from non English speaking backgrounds (57% of recent GSM PA s and 55% of 457 visa temporary arrivals). Further, pre-registration requirements have increased rather than diminished in recent years, with particular impact on migrant nurses, physiotherapists and pharmacists. A second employment barrier for migrants concerns the length of time required to secure Australian vocational registration, on a full rather than a limited basis. Migrants with the latter practise in an invidious professional situation. As a condition of eligibility for skilled migration, GSM primary applicants are obliged to submit their qualifications and evidence of good standing for pre-migration screening by the delegated Australian authorities, either on or offshore a process continuing since the establishment of the AHPRA together with the 10 national boards 7. Five examples of this qualifications assessment process are provided below, first in relation to medicine where significant data exist (Section 4), followed by recent trends in nursing, dentistry, physiotherapy and pharmacy where far more limited data are available (Section 5). The Impact of Screening Requirements Victorian and Western Australian Case Studies As previously noted, substantial numbers of medical and allied health professionals commence the qualification screening process onshore, having arrived as the dependents of GSM primary applicants or within the family and humanitarian categories. These migrants are at great risk of professional displacement Vietnamese and Chinese doctors, for example, taking up to 10 years to secure Australian medical employment 155. Assessment of medical training standards is a complex, time-consuming and a multi-faceted task. A range of informants also noted that complexity has increased in recent years, despite COAG and AHPRA attempts at reform and streamlining since By ,981 institutions were listed by the US International Medical Education Directory large numbers established in recent decades in Asia and Africa, with minimal publicly available data on the nature and caliber of clinical or pre-clinical training 156. The consequences can be significant. For example the Rural Workforce Agency, Victoria defined the following impediments in its 2011 Submission to the Finance and Public Administration References Committee for the Inquiry into the Administration of Health Practitioner Registration by the Australian Health Practitioner Regulation Agency (AHPRA): Attachment A outlines the complexity of the process involved in recruiting general practitioners into vacancies in rural Victoria. This demonstrates that the system as a whole is an extremely complex process for both practitioners and employers that involves multiple regulatory and administrative applications and approvals at multiple stages. (RWAV has made a submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors.) Delays can result in practices losing potential recruitments and/or practices 7 To date these include medicine, nursing and midwifery, dentistry, pharmacy, physiotherapy, optometry, podiatry, psychology, chiropractic and osteopathy, with additional boards to be established in

91 withdrawing offers of employment due to the length of time it takes the candidate to obtain medical registration. Such delays can deter potential candidates thus undermining the intention of the legislation to ensure workforce mobility and flexibility. Communities of need such as rural, remote and aboriginal communities with workforce shortages are very reliant on the recruitment of GPs, especially IMGs. Delays are both socially and economically costly to the communities and patients. This compromises the sustainability of fundamental health services to communities of high health need. For example, an IMG seeking employment in Australia may need approvals from: Verification of education and qualifications by the Educational Commission for Foreign Medical Graduates (ECFMG) English Language requirements Australian Medical Council for recognition of qualifications and certified paperwork Accredited Pre-employment Screening Clinical Interview Provider (PESCI) APHRA for registration approvals RACGP/ACRRM for the recognition of prior overseas general practice experience, Fitness for Intended Clinical Practice Interview (FICPI), approvals for the specialist pathway, Fellowship exams Department of Immigration and Citizenship Medicare Australia for provider numbers Department of Health and Ageing for District of Workforce Shortage for the approved vacancy State Government recommendations on Area of Need Approval for eligibility for a specific IMG programs Due to the significant challenges and complexity of the current system, RWAV has introduced a case management process to assist practitioners navigate the process and support them in their paperwork to achieve registration and employment 157. It is relevant to note Western Australia has experienced a recent plummeting of IMG applications, in the context of tightened Australian registration requirements. According to a key informant from Rural Health West, Western Australia has Australia s highest level of dependence on IMG s for regional/remote GP supply (53%). Since the 2008 introduction of the national assessment process however, the relocation of IMG s from overseas to WA has reduced by 80%: Before 2008 rural WA was recruiting primarily from the Sub-Sahara region, Sri Lanka, India and South Africa. Obviously with the National Assessment process their pathway into registration is very limited. It has certainly stopped them going to solo general practice towns. They might be looking to come to WA but there s (almost) no way we can be looking to put them into rural, because we have the highest incidence of solo GP towns in rural Australia. Between 2000 and 2008 the number of IMG s going through the Medical Board who ended up working in rural WA was around 120 a year. Then in 2008 that dropped to 24, and then about 20. Since then it s slightly increased to about 30 but in our view it will never return to the heady days of pre National Assessment The major challenge is to meet demand in general practice solo towns. The need is not being met. There are now about 7 towns that don t have a permanent doctor. So those communities are either travelling very long distances to get access to their primary care, or there are a range of locum workforce solutions. They aren t however really locums. They re out there for a month or two months really a back-fill situation. The consequences are that the market rate now for a locum is around $1,800-$2,000 a day. 90

92 Most of the local government authorities are footing these extraordinary bills, to keep some kind of access available for their communities The hospital locum rates are also just extraordinary. They re more like around $2,500 a day. It is essential to weigh these trends against recent cautions of over-supply in the medical workforce, including Birrell s view that there is no longer any justification to register IMGs who have not completed registration Australian Medical Council Assessment Outcomes Australian Medical Council Roles Australian medical courses are assessed and accredited by the Australian Medical Council (AMC), since July 2010 under contract to the Medical Board of Australia. To secure registration to practice, domestic and international students qualify through 4-6 year degrees followed by a year of supervised rotations (internship) - course length reflecting whether they commenced as school leavers or graduates. The AMC is also the gazetted authority to assess IMG qualifications pre and post-migration, for GSM selection as well as to secure full registration. Overseas qualified medical practitioners are required to demonstrate their completion of a medical degree or diploma (based on at least 4 years full-time academic study at a recognised university), pre-registration clinical experience, full registration in their country of training or practice, and a certificate of good standing from the relevant registration authority. The Literature on Barriers for Medical Migrants in Australia As we have seen, state/territory competition to recruit and retain medical migrants has intensified in Australia in recent years, a process leading to significant accreditation variations 159. Please note that a substantial literature has developed on IMG s access to medical employment in Australia, commencing with a seminal 1975 study conducted by Egon Kunz entitled The Intruders Refugee Doctors in Australia. This literature cannot be explored here, however persistent themes include: The scale and drivers of global medical migration to Australia; Australia s level of reliance on IMG s for regional, remote and public sector practice;; Barriers to IMG s securing full vocational registration; The degree and justifiability of professional protectionism exercised by Australian regulatory bodies; IMGs preparatory and concurrent medical training needs, including initial fitness to practise; and Factors influencing their long-term retention, in Australia and within regional or remote sites 160. Research on Pre-Registration Barriers for IMG s ( ) The most detailed study of international medical graduates to date, commissioned by Australia s Department of Health and Ageing (DoHA), demonstrated just a third of recently arrived medical graduates in 2005 even attempted the AMC s pre-accreditation exams. Despite this, a mail-out survey of 3,000 IMG s who had made at least one multiple choice question (MCQ) attempt in their first 5 years of residence revealed 78% to be medically employed at the time of the survey, though just 41% had then secured full registration. 91

93 The study established that candidates taking the AMC exams were derived from 139 source countries, reflecting the growing diversity of Australia s medical migration. Over 3,000 medical schools and universities were reported a third higher than the 1,981 institutions listed by the International Medical Education Directory in Further, substantial numbers of IMG s had obtained their qualifications through study outside their region of birth. Just 58% of doctors from Africa (excluding South Africa), 64% from North East Asia, 67% from South East Asia-Commonwealth, 79% from Oceania, 81% from Central Asia, 83% from North America, and 86% from Other Americas had qualified in their home country many Asia-Commonwealth doctors, for instance, having received some level of training in the west 162. Detailed analysis of the AMC database from January 1978 to late 2005 revealed the following key trends 163 : Overall, 81% of candidates who had attempted the MCQ written examination eventually passed it, with 51% doing so on their first attempt, 47% on their second attempt, but diminishing success evident over subsequent efforts (with a small number of candidates making 10 or more attempts). Table 26: MCQ Pass Rate by Region and Age Tertile ( Australian Medical Council Examination Candidates) Candidate Region of Origin Age at 1st MCQ Attempt, Tertiled <32 32 to Australasia 82% 85% 90% Oceania 94% 77% 73% UK/Ireland 96% 96% 86% North West Europe 87% 84% 66% South East Europe 77% 73% 69% East Europe 77% 71% 65% North Africa/Middle East 89% 84% 73% South East Asia-Commonwealth 90% 84% 67% South East Asia-Other 68% 74% 67% North East Asia 86% 84% 79% South Asia 87% 87% 82% Central Asia 82% 69% 84% North America 91% 93% 77% Other Americas 78% 66% 59% South Africa 93% 83% 71% Other Africa 80% 76% 48% Source: The Registration and Training Status on Overseas Trained Doctors in Australia, L Hawthorne, G Hawthorne & B Crotty, Department of Health and Ageing, 2007, Canberra, Table 3.3. Significant differences in MCQ pass rates were evident by region of origin: the highest for the UK/Ireland (95%), South Africa (86%) and North America (86%), and 92

94 the lowest for Other Americas (67%), South East Asia-Other (70%) and East Europe (70%). In other words possession of native English language ability, as well as training in medical systems directly comparable to Australia s proved highly advantageous. (See Table 26.) In addition to candidates country of training, recency of qualification, age and English language ability had significant impact on MCQ outcomes. For example 83% of candidates attempting the MCQ within 4 years of medical training passed it, compared to 83% of those qualified 5-9 years, 80% years, and 68% 20 or more years. Older candidates found it harder to pass the MCQ, though this was clearly mediated by country of training. While the overall pass rate for candidates sitting the Clinical examination (CE) was 86%, just 53% of all doctors presenting for the MCQ passed the CE in the study period ( ), with the number of candidates steadily increasing throughout the 1990s. The regions with the highest ultimate CE pass rates were South Africa (66%) and the UK/Ireland (64%), while the regions with fewer than 50% of candidates passing were South East Asia-Other (non-commonwealth) (38%), Other Americas (41%), South East Europe (49%), and Central Asia (49%). The median number of attempts was 1.0, with persistence beyond two candidatures rarely useful. (See Table 27.) Table 27: Clinical Examination Pass Rate by Region and Age Tertile ( Australian Medical Council Examination Candidates) Region Age at 1st MCQ, Tertiled <32 32 to Australasia 57% 60% 50% Oceania 63% 59% 51% UK/Ireland 66% 69% 50% North West Europe 66% 56% 34% South East Europe 59% 56% 40% East Europe 60% 60% 44% North Africa/ & Middle East 71% 63% 46% South East Asia-Commonwealth 61% 52% 39% South East Asia-Other 40% 50% 31% North East Asia 63% 57% 41% South Asia 60% 59% 44% Central Asia 54% 46% 50% North America 73% 55% 51% Other Americas 45% 47% 34% South Africa 74% 65% 47% Other Africa 65% 67% 18% Source: The Registration and Training Status on Overseas Trained Doctors in Australia, L Hawthorne, G Hawthorne & B Crotty, Department of Health and Ageing, 2007, Canberra, Table

95 Age in relation to passing the CE also proved very significant. In half of all regions assessed, higher proportions of medical candidates requiring 3+ attempts to pass were older. When compared with candidates aged <32 years, those aged years were 28 % less likely to pass the CE, while those aged 37+ years were 68 % less likely to do so. Region of origin was once again very important. Overall, when compared with doctors from English-speaking background regions, those with a European background (most in the study from South East and East Europe) were 38% less likely to pass the CE, those from Asia-Commonwealth countries 25% less likely to pass, and those from all other world regions 48% less likely to pass (most such candidates derived from non-commonwealth source countries). Doctors from North Africa/Middle East however were just as likely to pass as those from Englishspeaking regions. This analysis of medical migrants performance in the AMC exams illustrates the complexity of temporary resident doctors practising, in a context where many currently do so without full accreditation 164. As demonstrated by a separate 2007 study, IMG s in general practice in Australia at this time were disproportionately likely to work long hours, to be located in smaller practices, to deal with more acute conditions, new patients, and cater to a higher proportion of the socially vulnerable (indigenous Australians plus patients of all backgrounds holding concession cards) IMG Survey Findings (DoHA Study) In addition to analysis of the AMC database, the Department of Health and Ageing commissioned study included a survey of recently arrived IMG candidates who had attempted the MCQ at least once in the previous 5 years. Of the 3,000 IMG s drawn by the AMC, 1,144 informants returned questionnaires, yielding a 42% response rate. The IMG survey allowed assessment of the extent to which doctors deemed active in the AMC pathway were engaged to date in the Australian medical workforce, including the degree to which their work was contingent on full or partial AMC (or other) registration. It also allowed exploration of the attributes of those AMC candidates most likely to gain work a critical issue in making a case for end-point exemption from supervised clinical training placements. The key findings to note from the survey analysis were as follows: ESB respondents (doctors trained in the UK/Ireland, South Africa, USA, Canada, New Zealand, Oceania) were significantly more likely to have secured general medical registration in Australia than other groups, while long established doctors from Other backgrounds presented the reverse pattern (despite their length of time and permanent residence in Australia). After adjustment for age, when compared with ESB IMG s, survey respondents from North Africa/Middle East were 2.3 times more likely to be non-registered, and European IMG s 2.5 times more likely to be non-registered. The key predictors of non-registration were region of origin and age group (international medical experience and year of arrival in Australia proving non-significant), with few respondents simultaneously following RACGP and AMC pathways (just 6%). 94

96 Ninety-nine percent of the survey sample had attempted the MCQ examination: 68% once, 21% twice, and 11% three or more times (males being 55% more likely than females to sit for the MCQ twice or more, with successive attempts likely to prove decreasingly beneficial). Region of origin proved critical to MCQ outcomes. Compared to ESB doctors, respondents from a European background (in this study primarily from East and South-East Europe) were 4.5 times more likely to sit the MCQ multiple times, with those from Other 8 backgrounds 2.5 times more likely to do so, and those from Asia-Commonwealth just 70% more likely. Overall 83% of respondents attempting the MCQ had passed it (almost identical to the AMC database outcome of 81%), with doctors from North Africa/Middle East less likely to fail than ESB doctors. Sixty-one percent of respondents had also attempted the CE by the time of the survey. Interestingly, no difference was found by region of origin in the number of attempts made (a finding challenging conventional wisdom, and worth keeping in mind in relation to IMGs employment outcomes). Forty-one percent of all respondents had passed the CE by the time of the survey (lower than the 53% for the AMC database, and perhaps reflecting the bias in survey responses towards relatively unsuccessful candidates). Gender once again proved significant in relation to this: males were 63% less likely to have completed the CE compared to females. Region of origin also mattered to ultimate outcomes. Compared with doctors from ESB source countries, IMG s from Europe were twice as likely to have failed, those from Asia-Commonwealth 2.8 times as likely, those from North Africa/Middle East 2.9 times as likely, and those from Other backgrounds (defined in this study as South East Asia-Other, North East Asia, Central Asia, Other Americas, Other Africa) an extraordinary 4 times as likely. Notwithstanding their registration status, 78% of survey respondents reported having secured some type of medical work in Australia by 2005: the highest likelihood of employment being for ESB doctors (93%) despite their comparative youth (eg the backpacker doctors), recent arrival and temporary status compared to North Africa/Middle East (82%), Asia- Commonwealth (74%), and Other doctors (68%). This finding was in line with CE results. When compared with ESB doctors, respondents from Europe and North Africa/Middle East were 3 times less likely to have obtained work in medicine, those from Asia-Commonwealth 4.7 less likely and those from Other backgrounds 7.6 times less likely to do so. This outcome confirmed the disproportionate disadvantage experienced in Australia by Other doctors, given they were 4 times more likely to have failed the CE, though comparable to other groups in terms of MCQ pass rates. In the context of the above findings, the authors concluded that IMG s from Other, Asia- Commonwealth, and (to a lesser extent) North Africa/Middle East would be disproportionately 8 In this study Other was used to cover a variety of minor source countries in South East Asia, North East Asia, Central Asia, Americas and Other Africa, not falling into other categories. 95

97 likely to require 12 month post-amc clinical supervised placements. However findings are generally reported with far less specific detail. 4.4 AMC Assessment Outcomes to 2010 The most recent IMG accreditation data can be found in the AMC s February 2011 submission to the House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors 166. From to ,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%. Pass rates rose (as previously noted) with subsequent attempts. By % of MCQ candidates passed overall (most in two attempts), and 94% passed the Clinical examination (a comparable pattern). As demonstrated by Table 28, pass rates by country of training however remained highly variable reported here for primary countries of training, and with multiple attempts counted. Findings of concern emerge from these data. 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 Filipino pass rate of 38%). Demand for the AMC exams however is increasing. In ,466 candidates attempted the MCQ, compared to 1,509 in Clinical attempts similarly rose from 887 to 1,258 within this period. Table 28: Australian Medical Council MCQ and Clinical Examination Outcomes by Select Country of Training (1 January 1978 to 31 December 2010) Select Country of Training Total MCQ Candidates Total MCQ Passes Total Clinical Candidates Total Clinical Passes Candidate Total India Sri Lanka Egypt Pakistan Philippines Bangladesh China Iran UK/ Ireland Iraq South Africa Myanmar Germany Nigeria Source: Table prepared from examination data provided in select tables in Australian Medical Council (2011), Submission to the House of Representatives Standing committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors, Australian Medical Council, Canberra, 4 February. As with the DoHA commissioned study, age was a critical variable in relation to AMC pass rates. From % of IMG s aged years passed the MCQ on their first attempt, compared to 46% aged years and just 31% aged over 50. Similar trends were evident in relation to the Clinical exam. (This is an important issue to bear in mind compared to former international 96

98 students.) 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). The most recent AMC Clinical examination outcomes (from ) are reported for the top 10 countries of training in Table 29. Candidates with the highest immediate pass rates had qualified in Sri Lanka and China (58%) this China pass rate a marked improvement on earlier years. IMG s next best placed had trained in Iran (56%), Iraq, Egypt and India (52% each). By contrast Filipino pass rates were relatively low (34%). Substantial numbers of candidates were re-taking the test the great majority securing a pass within two attempts, as previously noted. Failure rates were minuscule for candidates qualified in South Africa or the United Kingdom. Table 29: Australian Medical Council Clinical Examination Outcomes by Top 10 Countries of Training ( ) Top 10 Countries of Training (Number) % Pass % Fail % Re-Test 1. India (1,823) Bangladesh (799) Pakistan (665) Sri Lanka (660) China (594) Iran (481) Philippines (437) Myanmar (374) Iraq (333) Egypt (277) Other countries (2,646) Total candidates (9,089) Source: Unpublished data supplied to Health Workforce Australia by the Australian Medical Council (June 2011). Additional studies have assessed IMG registration outcomes. For example a recent analysis of GP Registrar Examination Results for found that international medical graduates were more likely to fail than Australian medical graduates (OR 0.39, 95%CI 0.25, 0.60) and generally achieved lower scores. However such findings were reported with minimal detail. 4.5 The Competent Authority Pathway The Model In terms of AMC accreditation, it is also 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 program

99 Based on the research evidence, the Competent Authority 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, namely: The Professional and Linguistic Assessments Board Examination of the United Kingdom The Medical Council of Canada Licensing Examination The United States Medical Licensing Exam The New Zealand Registration Exam for Overseas Doctors General Medical Council accredited medical schools in the United Kingdom Medical schools in Ireland accredited by the Medical Council of Ireland Within the Competent Authority model, IMGs country of original qualification is deemed less important than their form of accreditation. To address ethical issues, for countries wishing to curb out-migration, nations can opt in or opt out of the Competent Authority pathway South Africa and Singapore choosing to opt out in the preliminary period, despite the level of Australian demand for such qualifications. Doctors fully accredited in one of the 6 systems, supported by a minimum of a year s Foundation Year/residency/rotations or not less than 12 months post-examination practice in a designated CA country are eligible to undertake the Competent Authority path without further assessment of medical knowledge or clinical skills 169. Following 12 months of Australian experience supported by light touch clinical supervision they can achieve full AMC certification a designated English language pass being their sole examination requirement. Comparable developments are underway in other professions, for example the new Certificate of Equivalence through the Australian Physiotherapy Council (with the support of AHPRA). The Impact of the Competent Authority Pathway on IMG Recruitment Global response to the Competent Authority pathway has been immediate and positive, associated with what might be termed transformational recruitment outcomes. According to Ian Frank (CEO of the Australian Medical Council), Up until 30 April 2010 we processed over 4,000 of (candidates) in the time period since August ,300 have been assessed as being eligible to proceed into the assessment pathways and went through, 1,700 have been granted AMC certificates and qualified for general registration. Now interestingly enough, of the total 4000, 2,200 have come out of the UK as UK graduates, and 860 of those have now completed all the steps of the process that we ve put in place. Before we introduced this, we were lucky if we had 50 UK graduates per year and in two years we ve got over 2,000. It is a very powerful attractor, and much to the chagrin of our Canadian colleagues not to mention our colleagues in the GMC, these (doctors) are nearly all young years out of UK university graduates, very well qualified. The feedback that we are getting from our hospitals where these people are located is that they are having no trouble with them and they are an ideal workforce So here was a pool of people that we knew in the UK were a bit fed up with the National Health Service, willing to get out, and (state governments) wanted to have some way of getting them here rather than them going to the US or Canada or somewhere else. And as I said if you compare this 1,000 per year to the 50 per year we were getting before, it is a very powerful attractor. 98

100 In terms of international medical graduates the AMC Competent Authority process has proven extraordinarily cost-effective to date. Since July ,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, as Frank notes, has also greatly enhanced Australia s global competitiveness 170. As demonstrated in Table 30, from the Competent Authority pathway attracted relatively young applicants, with 54% of those issued Advanced Standing Certificates aged years compared to 38% aged UK trained applicants were the major beneficiaries (1,019), followed by IMG s qualified in India (422) and Ireland (176). (See Table 31.) Table 30: AMC Competent Authority Pathway Outcomes by Age of Applicant ( ) Outcomes Age groups Total (years) No. No. No. No. No. Receipt of Application Total Advanced Standing Certificate issued Total AMC Certificate issued Total Source: Unpublished data supplied to Health Workforce Australia by the Australian Medical Council (June 2011). 4.6 Additional Medical Registration Pathways For international medical graduates requiring greater periods of adjustment, alternative pathways are being designed to provide enhanced supervision, address differential levels of training need, and increase readiness for specific locations of practice (eg remote practice and/or solo sites) 171. The Workplace-Based Assessment pathway, for example, is being trialled by the Hunter New England Area Health Services (NSW), the Rural and Outer Metropolitan United Alliance (Victoria), the Launceston General Hospital (Tasmania), Western Australia Health, Bunbury Hospital, Hollywood Private Hospital and the Joondalup Health Campus as part of the COAG IMG initiative 9. 9 While it had been hoped to report on the trial outcomes in this Scoping Report, the findings had not been cleared for release at the time of writing. 99

101 According to the AMC, the Workplace-Based Assessment model has significant potential value, with MCQ and English passes first required: The assessment are undertaken over time, providing a much more reliable and accurate evaluation of the clinical skills of the IMG. The IMG is assessed in terms of his or her performance rather than competence alone. In other words they are assessed in relation to how they perform in a clinical setting rather than measuring their capabilities in an artificial examination setting. The assessment includes feedback on performance which assists in addressing performance problems and issues, a function that is not available in the AMC clinical examination, unless these can be linked to bridging programs. The IMG s are employed and are better able to offset the cost of their assessments 172. Table 31: AMC Competent Authority Pathway Outcomes by Top 10 countries of Training ( ) Country of Training Receipt of Application (No.) Advanced Standing Cert. Issued AMC Certificate Issued 1. UK Ireland India Pakistan USA Sri Lanka Canada Myanmar Iraq Bangladesh Other countries Total Source: Unpublished data supplied to Health Workforce Australia by the Australian Medical Council (June 2011). According to Frank, there have been a number of challenges however associated with establishing Workplace-Based Assessment, including the national design, validation and administration of common assessment instruments: (The model) was mooted in the original COAG initiative in (Candidates) had to do the multiple choice exam at the front end and then they would have to do a workplace based assessment in clinical competence in place of what we normally do, which is a multi-station OSCE examinations.. What we are trying to do is design assessment instruments that can be undertaken during their hospital employment so you don t have to pull them out at some point and put them through the exam part of the process and then put them back in again. (Instead) you can assess them in the workplace. The advantage for us aside from the fact that it pulls (IMG s) out of our clinical exam queues, you are assessing them over time and in the workplace setting - which means that you are actually assessing their performance not their competence. So we believe that it is a much more reliable assessment instrument. But although it was rolled out and approved and signed off by (select) Chief Ministers and the Prime Minister it has been very slow in getting going. (In the trial programs) the numbers are fairly small. 100

102 Like Competent Authority and standard AMC candidates, IMGs undertaking the Workplace- Based Assessment pathway require 12 months of supervised clinical practice to complete a problem given the scale of IMG demand and available supervisory infrastructure. 4.7 Medical Specialist Registration Overview Scale and Source of IMG Specialists The scale of IMG arrivals with medical specialist qualifications is also significant explored in brief detail below related to surgery and psychiatry (fields with longstanding reliance on international medical graduates).. From ,612 IMG specialist assessment applications were received by the AMC. The majority were from males (69% of the total), with the top 10 specialist countries of training as follows: 1. UK (3,009) 2. India (2,712) 3. South Africa (1,084) 4. USA (647) 5. Germany (468) 6. Sri Lanka (372) 7. Ireland (226) 8. Iran (205) 9. Canada (202) 10. Philippines (152) Assessment outcomes for medical specialists however varied markedly by country of training, as demonstrated in Table 32, 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. Table 32: AMC Specialist Assessment Pathway Outcomes by Top 10 Countries of Training ( ) Outcome Rank Receipt of Country of Training Application Partially Not Comparable Comparable Substantially Comparable No. No. % No. % No. % 1 United Kingdom India South Africa USA Germany Sri Lanka Ireland Iran Canada Philippines Other Countries Not Stated Total Source: Unpublished data supplied to Health Workforce Australia by the Australian Medical Council (June 2011). 101

103 Specialist Assessment Outcomes AMC specialist applicant numbers and outcomes also varied markedly from by field. (See Table 33.) Applicants qualified in anaesthesia (843), psychiatry (747), obstetrics and gynaecology (507), diagnostic radiology (512) and general surgery (391) dominated, with orthopaedic surgery ranked eighth. Table 33: AMC Specialist Assessment Pathway Outcomes by Top 10 Specialties ( ) Outcome Rank Speciality Receipt of Application Partially Not Comparable Comparable Substantially Comparable No. No. % No. % No. % 1 Anaesthesia Psychiatry Obstetrics and Gynaecology Diagnostic Radiology General Surgery General Medicine Paediatric Medicine Orthopaedic Surgery Anatomical Pathology General Practice Other Specialties Total Source: Unpublished data supplied to Health Workforce Australia by the Australian Medical Council (June 2011). Unsurprisingly, IMGs seeking specialist AMC assessment proved to be significantly older than the norm (a trend with productivity implications). 443 candidates were aged years, 6,093 aged years, 3,876 aged years, 968 aged 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. In terms of outcomes just 15% of migrant general surgeons at this time were deemed substantially comparable compared to 20% of psychiatrists and 29% of anaesthetists. Male applicants dominated in select fields (as in Australia) the source for example of 622 general surgeons in compared to just 77 females, and 400 orthopaedic surgeons compared to 12. Females were the major specialist source in obstetrics and gynaecology (472 applicants compared to 398 males). There was near gender parity in paediatric medicine and anatomical pathology. Two brief case studies are provided below, to illustrate Australia s level of dependence on IMG specialists by field in the past decade. Minimal investigation of this has yet occurred, despite some analyses (for example in AMWAC studies) 10. It is worth noting migrant specialists were not 10 There are a range of references to overseas trained IMG s in specialist fields in the comprehensive Australian Medical Workforce Advisory Committee reports. For a list of reports please see accessed 12 August In-depth analysis of the role of overseas-trained specialists has been lacking to date, including in the impressive series of workforce reports prepared by the Australian Institute of Health and Welfare. 102

104 examined as part of the 2009 KPMG National Health Workforce Taskforce report, Health Workforce in Australia and Factors for Current Shortages Specialist Registration Surgery (Case Study 1) Australia s Level of Reliance on IMG Surgeons by 2003 Provision of surgical services in non-metropolitan Australia has long been problematic - key reasons being demography and a shortage of Australian surgeons willing to practise in the public sector and/or in regional areas 174. As early as % of Australian surgeons were aged 55 years or more. According to senior Royal Australasian College of Surgeons (RACS) informants interviewed several years back, while there was reasonable access to surgeons in regional Victoria, the situation could be described as acute in New South Wales and in pockets of South Australia and Western Australia, and disastrous in regional Queensland. A range of towns in New South Wales wholly lacked surgeons, or had surgeons unable to function due to unfilled related positions (eg anaesthetists). In 2003, for instance, Dubbo was reportedly reliant for surgical services on Royal North Shore Hospital. Virtually no ENT surgeons were available west of the Blue Mountains, and there was only one Advanced Surgical Trainee position west of the Great Divide. Tamworth had no urologist but was about to get one who will be the sole urologist in that vast area up to the north. Queensland from Mackay to Gladstone was described a black hole in terms of surgery. The scale of these problems was being addressed in part by the RACS locum service. Within this context Australia had become increasingly reliant on IMG s for the provision of surgical practice in three contexts. First, a substantial stream of overseas-trained surgeons entered Australia each year under the temporary Occupational Trainee category. According to one senior informant in Victoria, Virtually all surgical units are dependent on having some overseas-trained surgeons there to help with the surgical workforce. At (major urban hospital) there are at any one time in the Department of Neurosurgery five to six overseas-trained surgeons These people are all very helpful to us, because they provide a major workforce. We pay them very little. The ones from Japan and China are paid nothing. There are two from South Africa who retrained with us and stayed on to work as neurosurgeons, great successes! Selection methods vary, some coming through institutional links, others through response to direct applications (of which) I get at least one a day. A second category of surgical employment characterised by reliance on overseas-trained surgeons was area of need positions in rural or regional Australia. Three streams of overseas-trained surgeons filled these positions by 2003: Surgeons recruited from the United Kingdom, the European Union and select Commonwealth nations, of whom minimal professional adjustment was perceived to be required. South African surgeons, attracted by the prospect of securing permanent resident status in Australia. Permanent resident IMG s already in Australia, who had not been trained in Commonwealth countries and had failed to secure full AMC accreditation. Problems related to the skills variability of the latter group, including serious limits to the availability of medical supervision, were highlighted by a number of informants in the RACS 103

105 commissioned study. The scale of such area of need appointments in surgery however continued to be substantial. While short term contracts were the norm until the late 1990s, overseas-trained surgeons by 2003 were able to work in area of need positions in NSW for up to ten years. This could represent an appealing option, particularly for overseas-trained surgeons required but finding it difficult to access highly competitive Advanced Surgical Training positions. At the same time the risk of exploitation for non-accredited IMG s could be serious in such sites. According to one key informant: I have to say and it s a generalization that there are a lot of employers (and area of health boards) out there who are using these overseas trained practitioners as cannon fodder, because they cannot or will not make their environment a safe and appropriate one, and they can get these practitioners to come and work with them under these conditions, because these poor people want to have a job The overseas practitioner becomes a captive they sit there for 10 years, they can t move anywhere else because they re not registered to do so, but the location is screwing them to the ground, paying them less, making them work in an unsafe environment, while they provide surgical services. You might say well at least they ve got a job, but that s not in the public (or the surgeon s) interests. In addition to the first two categories, by 2003 there was a substantial pool of overseas-trained doctors employed as non-accredited surgical registrars in theory for a limited time (one to two years) but in practice for far more extended periods. At the time of the RACS-commissioned study, no one could quantify the number. Such doctors worked on a demand-driven basis in positions offering similar pay to that of accredited Australian trainees. They reportedly performed a comparable range of surgical procedures (there being no formal definition of those which could or could not be undertaken by non-accredited surgeons) 175. These IMGs were drawn from the pool of overseas-trained doctors who had failed to achieve full accreditation to date, and were unable to competitively secure Advanced Surgical Training (AST) positions. While in the past a few lateral entry places had been reserved annually to facilitate the entry of overseas-trained surgeons (reportedly one annually in New South Wales), this pathway was subsequently abolished. According to key informants, public sector patients might have no knowledge of whether they were being seen by accredited or non-accredited surgeons. This could be problematic, as indicated by the following senior surgeon: Some people see benefits to the current system: Basic Surgical Trainee (BST) and other non-accredited surgeons getting experience (not being wasted), the workforce being fairly elastic, the potential to attract people to unfilled locum positions etc. Many ex-bst trainees become career medical officers, contributing to a ratio of around 50:50 accredited compared with non-accredited surgical registrars. Non-accredited surgeons get all the jobs accredited surgeons don t want to do (eg night duty, locum duty, rural/regional public sector employment). The College has no real idea how many overseas-trained surgeons are filling these surgical positions Australia probably often uses overseas-trained surgeons people unlikely to secure AST positions Assessment Trends From 2004 to 2010 Australia s level of reliance on IMGs with surgical qualifications grew substantially. In applicants for assessment by the AMC specialist pathway were assessed, doubling to 238 in 2010, making a 1, total. A similar trend was evident in orthopaedics 38 applications received in 2004 compared to 61 in 2010 (yielding a 412 total). 104

106 While it is beyond the scope of the current paper to assess fitness for practice, it should be noted that a substantial body of literature has evolved in relation to the Dr Jayant Patel case and surgical practice at Bundaberg (Queensland) 176. Until 2010 no Australian research on medical complaints existed in relation to generalist or specialist international medical graduates. Indeed, there has been minimal research on this issue worldwide. A current University of Melbourne doctoral study by Elkin 177 is assessing Australian compared to New Zealand medical complaints data by key variables, including country of birth and training. This research is due for completion shortly. 4.9 Specialist Registration Psychiatry (Case Study 2) Australia s Level of Reliance on IMG Psychiatrists by 2003 Virtually identical trends to those defined for surgery prevail in the field of psychiatry, as documented by a 2003 review 178. Australian city hospitals remain characterised by strong training programs, a high degree of registrar loyalty, world-class research and a tradition of collegiality. By contrast mental health services in outer Australian cities as well as in regional and rural locations have long been characterised by a gross shortage of psychiatrists. According to Sir David Goldberg (a prominent UK psychiatrist) the exodus of Fellows from public sector psychiatry in Victoria by 2000 had resulted in the recruitment of psychiatrists from overseas who frequently did not possess the benchmark qualification for Australian psychiatrists 179. An Australian Medical Workforce Advisory Committee survey of 52 of these overseas trained psychiatrists (OTP s) noted that no fewer than 45% were employed in the state of Victoria. These doctors were overwhelmingly concentrated in rural areas: 43% of those surveyed, compared to just 9% of Royal Australian and New Zealand College of Psychiatrists Fellows across Australia 180. In addressing public psychiatry shortages, mental health authorities by 2003 were recruiting from a wide range of source countries, including the UK, South Africa, Canada, the US, select Commonwealth nations, and a group of medically under-resourced nations. There were serious ethical issues here, including the appropriateness of wealthy western nations deriving specialists from countries in desperate need of their services. The global context however was one of sustained migration from south to north, from east to west, and from developing to developed nations. These movements show no sign of abating. Once offered psychiatric employment, overseas trained psychiatrists in the past decade were typically registered in Australia by the relevant state Medical Board to practise for a year or more in a defined public health setting. Given the intensity of demand for mental health services, most were expected to hit the ground running. No period was often provided for acclimatisation, training, or induction into the particular local skills required for practice of psychiatry in Australia. While recognition protocols have differed from state to state, overseas trained psychiatrists have nominally been required to complete the College s requirements within a period of four years, though this timeframe has been lenient in the past decade due to chronic undersupply. At their point of arrival many migrant psychiatrists would have been deemed suitable for practice, but little more of their skills may have been known. Within days the majority reportedly found themselves consumed by the demands of public sector practice. In one instance noted in the 2003 study, an overseas trained psychiatrist was appointed Acting Director of Mental Health Services, before being apprised of the relevant Mental Health Act, let alone trained in local pharmacology practices or treatment norms. Some became the only professional psychiatrist in the public sector service, on call 24 hours a day seven days per week, across a vast geographical area. This 105

107 reliance, by definition, was potentially exploitive of overseas trained doctors, and risked compromised quality of service. In addition to this, it should be noted that large numbers of generalist IMG s secure their first Australian medical positions in junior public sector psychiatry positions, regardless of a lack of specialist qualifications. Many such doctors will be sojourners, moving to more desirable positions as soon as these become available. In the interim they will be required to assess patients entering hospital in emergency situations, included attempted suicides and people who are acutely psychotic. Their lack of preparatory training for this work is problematic Assessment Trends From 2004 to 2010, Australia s level of reliance on IMG s with psychiatry qualifications grew rather than diminished. In applicants for the AMC specialist pathway were assessed, rising to 199 in 2010, making a total of 1,285 migrant applicants across this period Conclusion Concerns continue to be raised concerning IMG s level of access to specialist registration. For example the RWAV submission to the House of Representatives Standing Committee on Health and Ageing/Inquiry into Registration Processes and Support for Overseas Trained Doctors (OTDs) stated: GPs with specialist skills such as anaesthetics, obstetrics and surgery are critical to the infrastructure of rural and remote health services. There is a significant shortage of GP Proceduralists, and this has led the Department of Health and Ageing to consider support for a GP Procedural Generalist Pathway for training GP proceduralists. There are many OTDs working in Australia with unrecognised procedural training skills and experience who currently have no clear pathway for their experience to be assessed and validated. These OTDs represent an untapped resource that could potentially assist the serious procedural shortages in rural communities 181. Having defined the situation in relation to medical registration, trends related to allied health migration and registration are next examined 106

108 Section 5: Access to Vocational Registration Allied Health 5.1 Nurse Migration and Assessment Far more limited data are available in relation to migrant allied health professionals, including factors associated with their level of access to vocational registration. This is remarkable given the scale of overall flows, and the numerical dominance of nurse migration. Section 5 examines migration and assessment trends in relation to nursing, dentistry, pharmacy and physiotherapy fields warranting substantial future research. The Role of the Australian Nursing and Midwifery Council To screen migrant nurse qualifications, State and Territory Boards two decades back collectively formed the Australian Nursing and Midwifery Council (ANMC, now ANMAC), which assesses pre-migration primary applicants on a fee for service basis. As with medicine, examination of qualifications in nursing can be highly problematic. An ANMC commissioned report, for example, was undertaken some years back to facilitate the assessment of qualifications from the Former Yugoslavia Republic (the source of substantial numbers of overseas-qualified nurses to Australia in the 1990s often through humanitarian flows). Taking just one of these new geopolitical nations as a case study, ANMC found: Research on the caliber of training required correspondence and documentation in six languages, across 13 states within the newly constructed nation. Wholesale systemic change had occurred from the commencement of war in 1991, through to the current period when the country is educationally influenced by the European Union. The nurse education system had been profoundly influenced in the past 20 years by war, partition and urgent health service shortages - in some periods leading to an abbreviation of study, followed by a reversion to training norms in peace. Despite the ANMC s best efforts, peak nursing bodies had been difficult to locate, with attempts to secure information eliciting minimal or no response. A further complication concerned the division between elite and baseline nurse training institutions (both accorded Registered Nurse status in the past), as well as the calibre of university compared to college and hospital RN training. Within such a context it could prove impossible to secure specific detail concerning curricula, clinical training, subjects, level of supervision, or expertise at specific points in time (essential in order to assess the registerability of individual nurses). Lacking such data, competency-based assessment in Australia was considered to remain essential 182. The Council has since had few funds to conduct further such research. In ANMC examined 2,502 migrant nurse applications (an increase of 22% on ), derived from 58 countries of origin. A typical applicant that year was female (88%), aged 34, and qualified as a Registered Nurse. 821 such applicants were deemed to require detailed assessment, while 1,681 others received modified assessment on the basis of known comparability of systems (eg Canadian qualified nurses). Major birthplace groups of applicants at that time were from the UK (36%), India (8%), the Philippines (6%), South Africa (4%), and Zimbabwe (3%). 107

109 Pre-Registration Barriers for Migrant Nurses The primary Australian study of nurse migration to date was conducted in the 1990s. While ESB nurses had passed easily into employment, NESB nurses had been obliged to address three major hurdles 183. 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 become more severe since.) 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. Finally, while both ESB and NESB nurses secured professional employment once registration had been 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. The Risk of Workforce Segmentation The risk of professional stratification for migrant nurses was very significant 184. The survey of 1,000 who had resident in Australia 1-15 years (eliciting 719 responses) was confined to those who had achieved full registered nurse (RN) status by the start of the study, in order to exclude non-registration as a cause of inferior outcomes. By 1996, 47% of the NESB nurse sample had found full-time work, compared to 40% of English speaking background nurses. Despite this, 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). A second critical indicator of professional success in Australia was the degree of labour market segmentation occurring in employment by sector. Among the 719 migrant nurse respondents, ESB males and females proved significantly more likely to be employed in private sector hospitals than NESB nurses ( 2 =19.01, p<0.01). Moreover West European nurses had exceeded ESB levels in this, once overcoming their entry disadvantages (passing the mandatory English test and securing access to professional registration). Other NESB nurses, by contrast, were found to be disproportionately clustered in public hospital positions (Commonwealth-Asian and East European nurses), or to be based in the stigmatised geriatric care sector (East European, Middle Eastern and non-commonwealth Asian nurses) ( 2 =51.45, p<0.01). 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: ). No comparable disadvantage was found for any other ethnic group studied, even those with similarly basic qualifications. Length of residence in Australia, while included in the nominal regression model, was found to have no significant impact on employment sector. This was a matter of serious concern, suggesting the potential of initial disadvantage for select overseas 108

110 qualified nurses to persist in Australia over time. Working in geriatric care while securing full registration, many NESB nurses had become trapped unable to make the case that they were qualified to work in the acute hospital sector. Recent Trends in Pre-Migration Applications to ANMAC ( ) Between 2007 and 2010 ANMAC 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). (See Table 34.) 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 have been provided by country of training to date, though these were sought for the Scoping Paper. Table 34: Australian Nursing and Midwifery Council Applications and Assessment Outcomes for General Skilled Migration (2007 to 2010) Top Countries of Application Nos. Top Countries of Application India 2437 India 453 UK 2358 China 421 China 1316 UK 378 Philippines 957 Philippines 266 Zimbabwe 471 Nepal 123 Korea 430 Korea 118 South Africa 329 Zimbabwe 100 Ireland 258 Ireland 72 Hong Kong 227 South Africa 51 Nepal 213 Hong Kong 49 Total 11,051 Total 2587 Source: Unpublished data derived from the Australian Nursing and Midwifery Council Yearly Data Report, accessed February Dentist Migration and Assessment The Growing Scale of Demand Dentistry features on Australia s GSM Skilled Occupation List, along with virtually every major health profession. Despite the scale of intakes being small, the significance of dental migration is rapidly growing. As demonstrated earlier, between 2001 and ,125 migrants with dental qualifications arrived (compared to 540 from ). By % of Australia s dental practitioner workforce was overseas-born, with 22% having arrived from (a major proportional contribution). India was the primary source at this time (320), followed by the UK/Ireland (125), North Africa/Middle East (128), the Philippines (88) and Central/South America (78). 109

111 From to , 512 GSM PA s were admitted, including 151 in (two-thirds selected offshore). The scale of arrivals had tripled since , when just 62 PA s were selected. A further 590 dentists reached Australia through the 457 temporary category in these 5 years, including 160 in (compared to 80 five years earlier). In there were 330 skilled category dental arrivals (180 admitted as GSM PA s and 150 in the 457 Visa category). This was in addition to unknown numbers of dentists accepted through the family and humanitarian categories. Australian Dental Council Functions Dental science courses are accredited by the ADC, which develops national accreditation standards for education and training leading to registration as dental practitioners and specialists (in addition to technologists, therapists and hygienists) 185. The ADC is also the gazetted authority to assess international dental graduates (IDG) qualifications pre and post-migration for GSM purposes, and access to full registration on arrival. The Council examines the caliber of IDG training in comparison to Australian practice standards, plus the knowledge, clinical skills and professional attributes of overseas qualified dental/ oral health practitioners who seek registration (since July 2010 advising the Dental Board of Australia on these matters). Demand for ADC Examinations and Outcomes Only New Zealand trained dentists are accorded automatic recognition, in line with the Trans- Tasman Agreement. In April 2010, the Dental Councils of Canada and Australia also agreed to mutual recognition subject to Canada s requirement for Australian graduates to sit their national exam. To secure registration to practice, overseas qualified dentists 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/Bangladesh 186. These outcomes 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 ,048 IDG s were deemed eligible for registration in Australia through the ADC assessment pathway an extraordinary contribution. Demand for assessment has grown markedly in this time. 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%. (See Table 35.) This scale of dental migration was unanticipated. In 2006 an Australian Institute of Health and Welfare report noted it is unlikely that numbers will increase much beyond 2006 levels as the ADC is nearing capacity for testing and processing 187. Dental migrants diversity, differential training systems, and levels of English represent major challenges, along with the resources required to deliver sufficient 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 very significant, in a context where IDG s are 110

112 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. Table 35: Australian Dental Council Applications and Assessment Outcomes for Registration (2000 to 2010) Year Assessment No. Preliminary Exam: Encounters Preliminary Exam: Completions Final Exam: Encounters Final Exam: Completions No. of Exams Source: Unpublished Australian Dental Council data, provided March Pharmacist Migration and Assessment The Recent Scale of Migration Pharmacy is not a key health workforce migration field to date. By 2006, there were 4,962 degree-qualified migrant pharmacists resident in Australia just 8% of the total pharmacy workforce, including 749 who had arrived in the previous 5 years. Reflecting this, limited public data exist on their employment or registration outcomes. In May 2010 pharmacists were also removed from Australia s new Skilled Occupation List a move anticipated to substantially cut GSM arrivals. An exception is the state/territory sponsored lists, which currently facilitate the entry of hospital, industrial and retail pharmacists. However temporary flows remained significant. The Qualifications Recognition Process To secure Australian registration to practice, domestic students qualify as pharmacists through 4 years of tertiary study - course length reflecting whether students commence with school leaver or graduate entry status. The Australian Pharmacy Council (APC) is the national body representing the Australian state and territory pharmacy registering authorities. Established in 2002, the APC s aim was to enable a national approach to pharmacy regulation and accreditation, supporting the registering authorities primary goal of protecting the public. In line with this the APC takes a leadership role in developing and implementing nationally consistent policies, processes and approaches to pharmacy practice, regulation and registration, accrediting pharmacy schools and programs, authorizing agencies to accredit continuing professional development activities, conducting examinations towards eligibility for registration, and assessing the qualifications and skills of pharmacy graduates towards Australian registration and permanent residency. 111

113 Key Challenges and New Developments in Foreign Qualification Recognition The challenges for migrant pharmacists are comparable to those described for other migrant health professionals - however, fewer bridging options exist given the modest scale of permanent arrivals. Within this context the APC has been responsible for initial paper-based review of qualifications, experience and English ability. In the top countries of training for stage 1 APC eligibility assessments were Egypt (38%), India (25%) the Philippines (10%), South Africa (6%) and Nigeria and Pakistan (3% each). A Competency Assessment of Overseas Pharmacists examination is then 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 were Egypt (52%), India (17%), Zimbabwe (4%), Pakistan, South Africa and Nigeria (3% each) 188. Following July 2010, and the establishment by AHPRA of the new Pharmacy Board of Australia, a period of change and reprioritizing of functions is underway. While the APC will continue to be responsible for initial assessment of qualifications, experience and English ability, following this eligible migrant pharmacists will undertake supervised practice and competency assessment under the Pharmacy Board of Australia (PBA) rather than the APC (a major change, noting APC had previously managed migrant pharmacists to their point of registration). An orientation information tool has recently been developed and trialled by the APC. The PBA has also approved the Accreditation Standards for Pharmacy Intern Training Programs 2010, and will oversee a written and oral examination for proof of competency and eligibility for full registration (with APC commissioned to develop and conduct the written component). The APC is further exploring the potential of computer delivery of examinations to enhance uniformity of procedure, delivery on the same day(s) and times, faster receipt of results, and greater security. 5.4 Physiotherapy Migration and Assessment The Scale of Demand Unlike pharmacy physiotherapists are currently included on Australia s Skilled Occupation List. Their numbers however are modest to date - just 2,409 degree-qualified overseas-born physiotherapists resident in Australia by 2006, including 469 arrivals the previous 5 years. An additional 394 recent migrants arrived in this period with diploma qualifications (unlikely to secure registration at the professional level). In consequence the APC has assessed a modest number of applications, though demand is trending up (from 93 in 2007 to 134 in 2010). Positive outcomes only are reported in Table 36 a total of 546 applicants being approved, most notably for physiotherapists qualified overseas in England (105) and India (51). 112

114 Table 36: Australian Physiotherapy Council Assessment Outcomes for Migrant Physiotherapists Who Obtained their APC Certificate (2007 to 2010) Sex Country of training no. no. no. no. no. Females Australia England (a) India New Zealand South Africa Ireland Canada Scotland Hong Kong Netherlands Other Countries Total Males Australia England (a) India New Zealand South Africa Ireland Canada Scotland Hong Kong Netherlands Other Countries Total Total Australia England (a) India New Zealand South Africa Ireland Canada Scotland Hong Kong Netherlands Other Countries Total Source: Unpublished Australian Physiotherapy Council data, provided April The Qualifications Recognition Process Australian courses are accredited by the APC. To secure registration to practice, domestic students qualify through 4-6 years of tertiary study - course length reflecting whether they commenced as school leavers or graduates (noting a range of professional courses are now offered at Master s and Doctoral level). Despite the small scale of migration flows to date, the 113

115 APC is deeply engaged with assessment and mutual recognition initiatives in terms of the GSM as the official gazetted authority. A separate APC role (as with other bodies) is assessment of migrant physiotherapists onshore applying for full registration. Along with English testing (IELTS 7 or a B on the Occupational English Test) a document-based assessment first occurs (Initial Assessment) the key criteria being applicants institution of training and recognition by the World Confederation of Physiotherapy. Once eligibility is confirmed, a Written Assessment MCQ test is administered, requiring a 55% grade to pass. Stage 3 involves a Clinical Assessment exam, where candidates interact with three patients while assessed by independent examiners. An Australian Physiotherapy Council Final Certificate is awarded on successful completion of this process 189. In 2010 the lowest number of applications was received in 6 years, with 134 approved in total. As with other fields, many applicants will pass a stage, but not proceed to full registration. Governance Changes Major changes to physiotherapy assessment are underway the most important since AHPRA s formation being the introduction of a Certificate of Substantial Equivalence from July 2010, which can be used to meet Australian qualifications requirements (an alternative to the examination pathway for select groups, and comparable to fast track developments in medicine). Following a 6 week evaluation process from application lodgement, the assessor s evaluation may result in approval for issue of an APC Certificate of Substantial Equivalence of Qualification, or an approval to apply to sit the Written Assessment, or no approval of equivalence. It is premature to assess any outcomes at this stage. 5.5 The Case for Bridging Courses 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. Very few exist beyond medicine and nursing. 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 years 190. According to the Medical Council of New Zealand 191, $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 (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 outcomes

116 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) Conclusion As is the case with medicine, allied health professionals face substantial barriers to securing Australian registration. These are most severe for family and humanitarian category health professionals, who typically commence the credential recognition process onshore, following arrival. It is impossible to review registration outcomes for allied health professionals by key variables at this stage (including the impact of country of training, gender and age), given the limited availability of assessment data. Within this context, the 2006 Census must remain our primary source, noting it demonstrates that: 53% of migrant medical practitioners (all categories) secured medical employment in Australia in their first 5 years post-arrival with relatively poor rates associated with doctors derived from China (6%), Indonesia (8%), Japan/Republic of Korea (14%), Vietnam (23%) and Eastern Europe (31%). 63% of migrant nurses/midwives (all categories) secured nursing employment in Australia in their first 5 years post-arrival the lowest rates associated with nurses from Central/South America (31%), North Africa/Middle East (33%), Indonesia (24%), Vietnam (25%), and Eastern Europe (44%). Just 37% of migrant medical practitioners (all categories) secured dental employment in Australia in their first 5 years post-arrival the lowest rates associated with dentists from Central/South America (5%), the Philippines (7%), China (21%), surprisingly India (23%), and Sri Lanka/Bangladesh (34%). (See Section 2, Tables 15, 17 and 18.) The factors contributing to these findings for allied health professionals warrant careful review. This represents a green field for Australian research. It is worth noting in relation to this that the OECD and WHO have placed strong recent focus on global nurse mobility a priority also for the International Council of Nurses. Countries as diverse as India, the Philippines, the UK, and New Zealand have expanded their research on nurse flows, alongside medicine 194. Little information exists however in relation to other allied health fields. 115

117 Section 6: Translation to Practice? Select Country Profiles 6.1 Introduction The analysis in the previous sections is inevitably complex: Section 2 defined the major recent sources of health workforce migration to Australia (focusing on permanent and temporary residents who were overseas-trained). Section 3 demonstrated the consequences of mandatory English language testing on their registration (taking the Occupational English Test as a case study). Sections 4 and 5 assessed Australia s vocational registration requirements and outcomes to July 2010 (comparing skilled to other immigration categories). Pre-registration hurdles exert a powerful cumulative impact, determining which migrant health professionals secure early labour market integration and which often for years - struggle to secure professional employment. See Table 37 for select outcomes by 2006, comparing employment levels for a range of source countries in medicine, nursing and dentistry (all immigration categories). Results for non-commonwealth Asia are particularly poor. Table 37: Labour Market Integration Rates for Migrant Medical, Nursing and Dental Professionals in the First 5 Years Post-Migration (2006 Census) Select Source Country/ Region ESB Countries % of Doctors Employed as Doctors % of Nurses Employed as Nurses % of Dentists Employed as Dentists South Africa 75% 79% 89% UK/Ireland 71% 76% 82% USA/Canada 48% 57% - Europe (excl. UK/Ire) West Europe 62% 54% - North Europe 51% 65% - South East Europe 39% 47% 69% East Europe 31% 44% - Commonwealth Countries India 61% 72% 45% Sri Lanka/ Bang. 56% 63% 64% Singapore 63% 86% - Malaysia 62% 64% 84% Hong Kong/ Mac 40% 59% - Non- Commonwealth M East/N Africa 47% 33% 58% Philippines 50% 58% 64% Cent/ S America 40% 31% 69% Vietnam 23% 25% - Indonesia 8% 24% - China 6% 53% 54% Source: Analysis of ABS Census data (2006), derived from Tables 12, 16 and 17 of the current study. 116

118 Within the recent period, large numbers of migrant health professionals have been defined as not in the labour force or unemployed with NILF typically a proxy for learning English and/or trying to satisfy regulatory body requirements. To highlight key patterns, the following section provides a snapshot of the characteristics and outcomes achieved by major birthplace groups - their selection based on the scale of recent flows, breadth across immigration categories, and/or cross-disciplinary relevance. Countries chosen for the analysis are New Zealand, the United Kingdom/ Ireland, South Africa, India, Malaysia, China, the Philippines, Iraq and Iran (emerging source countries for Australia in Other Southern and Central Asia ) and Egypt. Data for the major English speaking background countries are summarised first, followed by countries associated with more variable employment outcomes. Following this, the outcomes achieved by former international students will then be examined (Section 7). 6.2 New Zealand (NZ) As noted at the start of the present study, 221,578 New Zealanders moved to Australia in the decade to 2008/09 (in the context of free movement via the Trans-Tasman agreement). Just 69,884 departed across all fields. Australia is thus a major beneficiary of NZ talent. In ,000 New Zealanders were resident, including very large numbers on a semi-permanent basis. In New Zealand was also the second top ranked source for GSM health professionals formal PR status conferring a range of practical benefits (including Medicare access). From to a total of 2,066 New Zealanders migrated, in addition to those entering Australia through informal mechanisms. The scale of temporary entry is unknown, given 457 visas for temporary workers were not required. In 2006 however, according to the Census, 1,247 nurses, 240 doctors, 44 dentists and 368 other allied health New Zealanders were resident who had arrived in Australia in the past 5 years. (See Table 38.) Counting all vintages of migration, 9,158 NZ health professionals were living in Australia at this time, in rank order contributing: Nurses: 5,905 Doctors: 1,163 Dentists: 196 Other allied health professionals: 1,894 New Zealand health professionals labour market integration rates were immediate and strong 195. In terms of medicine, for example, 88% were professionally employed by 2006 (58% in medicine and the remainder in other fields). None reported taking low skilled work, and just 1% were unemployed. Twelve percent were categorized as not in the labour force at this time likely to be for family reasons or study, noting that New Zealand trained professionals were exempt from English language assessment or credential recognition requirements. Findings were similarly strong for NZ professionals in the other two fields examined, as follows: Nurses: 79% employed (including 62% in nursing and 2% in another profession), 1% unemployed, and 20% not in the labour force Dentists: 94% employed (including 86% in dentistry and 3% in another profession), nil unemployed, and 6% not in the labour force It is important to note however that fluidity under the Trans-Tasman agreement can work both ways. From to New Zealand was the second top source of health professional 117

119 emigrants from Australia 2,066 in total, including 392 in (ranked 14 th that year - see Section 8). Table 38: Scale of Health Workforce Migration by Select Birthplace, by Period of Arrival (2006 Census) Year of Arrival (a) Pre-1996 New Zealand UK / Ireland Other Europe Viet Nam Malaysia Philippines China (excludes SARs and Taiwan Province) No. No. No. No. No. No. No. No. No. No. No. No. Medical 735 3,658 2, , , ,419 17,091 Dental ,244 Nursing & Midwifery 3,914 14,358 4, ,668 2, ,699 38,646 Allied Health 1,304 4,237 2,042 1, ,761 16,111 All Other (b) 146, , ,030 67,998 35,067 49,693 46,961 27,772 35,984 29, ,529 1,524,126 Total 152, , ,377 70,771 40,959 52,779 48,937 30,610 38,433 32, ,241 1,599,218 Hong Kong (SAR of China) India South Africa Other Total Medical ,084 3,053 Dental Nursing & Midwifery 744 1, ,271 5,266 Allied Health ,487 All Other (b) 37,815 32,925 26,552 5,452 4,355 8,996 18,482 4,595 13,531 12,789 70, ,200 Total 38,997 35,288 27,559 5,532 4,881 9,559 19,055 4,872 14,113 13,655 73, , Total Overseas Born Medical , ,786 5,324 Dental Nursing & Midwifery 1,247 3, ,344 10,647 Allied Health ,022 All Other (b) 44,294 56,781 26,239 4,142 7,677 10,301 26,358 3,280 32,991 15,967 94, ,389 Total 46,193 62,204 27,399 4,173 8,232 11,290 27,009 3,468 35,054 17,538 99, ,930 Medical 1,163 4,935 2, , ,743 1,408 7,289 25,468 Dental ,150 4,184 Nursing & Midwifery 5,905 19,406 5, ,915 3,977 1,431 1,111 1,458 1,812 10,314 54,559 Allied Health 1,894 5,521 2,382 1,348 1, , ,281 5,149 21,620 All Other (b) 228, , ,821 77,592 47,099 68,990 91,801 35,647 82,506 58, ,596 2,082,715 Total 237, , ,335 80,476 54,072 73,628 95,001 38,950 87,600 63, ,498 2,188,546 Source: Analysis of 2006 Census data provided by the Australian Bureau of Statistics (2011). Note: There are slight variations in the numerical data compared to the 2006 Census data separately prepared by the author and G Hawthorne, for UNESCO in United Kingdom/Ireland A similarly positive picture emerges in relation to UK/Ireland trained health professionals. From to the UK/Ireland were the source of 5,370 health-qualified migrants to Australia, selected through the GSM program. In , they ranked first as a source overall. The scale of 457 visa arrivals was greater however, with a total of 10,910 employer-sponsored arrivals from to the UK/Ireland Australia s the top temporary source country in (with the global financial crisis spurring migration) 196. In 2006, according to the Census, 3,654 UK/Ireland nurses, 852 doctors, 123 dentists and 794 other allied health professionals were resident in Australia who had arrived in the previous 5 years. Counting all vintages of migration, an extraordinary 30,494 UK/Ireland health professionals were thus resident in Australia, in rank order: Nurses: 19,406 Doctors: 4,

120 Dentists: 632 Other allied health professionals: 5,521 The labour market integration rates of UK/Ireland migrants were strong, as with New Zealand. In terms of medicine 85% were professionally employed by 2006 (71% in medicine and the remainder in other fields). None reported having less skilled work, and none were unemployed. Twelve percent were categorized as not in the labour force at this time, the same rate as for NZ and Australia. The UK/Ireland born were exempt from English language assessment, and confronted minimal AMC barriers: MCQ pass rate (1978 to 2010): 84% (646 out of 772 candidates) MCQ pass rate ( ): 83% (progressively removed from the list given transition to the Competent Authority pathway) Clinical pass rate (1978 to 2010): 84% (454 out of 539 candidates) Competent Authority pathway ( ): UK top source of candidates from (2,784 applications, translating by 2010 to 1,976 Advanced Standing Certificates and 1,019 AMC Certificates); Ireland the second top country of training (631 applications, translating by 2010 to 483 Advanced Standing Certificates and 176 AMC Certificates) Scale of specialist assessments ( ): 3,009 UK applications (top source country) compared to 226 from Ireland (7 th top source country) Specialist assessment outcomes ( ): 76% of UK qualifications deemed substantially or partially comparable, along with 75% of Irish qualifications Employment outcomes were similarly strong for UK/Ireland migrants in the other two fields assessed. Key findings for nursing/ midwifery were as follows: Employment outcomes for arrivals (2006 Census): 79% employed (including 62% in nursing and 2% in another profession), 1% unemployed, and 20% not in the labour force ANMAC pre-migration assessment : UK second top country of application (2,358), and Ireland eighth top country of application (258) noting no recognition outcomes by source country were made available ANMAC pre-migration application rates 2010: 378 from the UK and 72 from Ireland Comparable findings for dentistry were as follows: Employment outcomes for arrivals (2006 Census): 87% employed (including 82% in dentistry and 5% in another profession), nil unemployed, and 13% not in the labour force ADC pre-migration assessment : No country of application data made available Regrettably, emigration trends could solely be sourced for health fields combined. From to the UK was the third top country of health workforce emigration (1,616 people, many of whom would have arrived on a temporary sponsored basis). This compared to 233 total emigrants from Ireland (Australia s third top source). The number of health professionals leaving in were 318 from the UK (11% of the total), compared to 36 from Ireland (1%). 6.4 South Africa Highly comparable trends are evident in relation to health workforce migration from South Africa. From to South Africa was the source of 580 GSM health-qualified 119

121 migrants, in , ranking 6 th overall. The scale of 457 visa arrivals was far greater, with a total of 1,770 employer-sponsored arrivals from to the 7 th top temporary source country in In 2006, according to the Census, 760 nurses, 430 doctors, 34 dentists and 347 other allied health professionals were resident who had arrived from South Africa in the previous 5 years. Counting all vintages of migration, 4,671 South African health professionals were living in Australia at this time, in rank order: Nurses: 1,812 Doctors: 1,408 Dentists: 170 Other allied health professionals: 1,281 South Africans labour market integration rates were exceptionally strong (an identical pattern prevailing in Canada). In terms of medicine 93% were professionally employed by 2006 (75% in medicine and the remainder in other fields). Like New Zealand and UK/ Ireland doctors no South African reported having less skilled work, while just 1% were unemployed. A mere 5% were categorized as not in the labour force at this time, lower than for NZ, the UK/Ireland and Australia. Minimal AMC barriers were experienced: MCQ pass rate (1978 to 2010): 74% (683 out of 924 candidates) MCQ pass rate ( ): 79% Clinical pass rate (1978 to 2010): 74% (444 out of 564 candidates) Competent Authority pathway ( ): Excluded by agreement with the South African government (as is also the case with Singapore) Scale of specialist assessments ( ): 1,084 applications (third top source country) Specialist assessment outcomes ( ): 80% of South African qualifications deemed substantially or partially comparable Employment findings were similarly strong in the other two fields assessed. Key findings for South African nursing/midwifery were as follows: Employment outcomes for arrivals (2006 Census): 86% employed (including 79% in nursing and 6% in lower skilled work), 1% unemployed, and 14% not in the labour force ANMAC pre-migration assessment : Ranked 7 th top country of application (329) noting no recognition outcomes by source country were made available ANMAC pre-migration application rates 2010: 51 from South Africa Comparable findings for dentistry were as follows: Employment outcomes for arrivals (2006 Census): 89% employed (all in dentistry), nil unemployed, and 11% not in the labour force ADC pre-migration assessment : No country of application data made available Interestingly, the OET was found to represent a significant barrier for the many South African health professionals who were not eligible for exemption. Thirty percent passed on their first attempt in 2005 (when passes on the 4 sub-tests over repeat sittings were allowed), while 43% passed overall. By % passed on their first attempt, with 66% securing an ultimate pass on a single sitting. 120

122 As noted, emigration trends could solely be sourced for all health fields combined. From to South Africa was the 11th top country of health workforce emigration (146 people, many of whom would have arrived on a temporary sponsored basis). The numbers leaving in were just 27 (1% of the annual total). 6.5 India As with the UK/Ireland, Australia has a huge dependence on India for health workforce migration. From to India was the source of 1,610 GSM health-qualified migrants, in , ranked second overall. The scale of 457 visa arrivals was vastly greater, with a total of 6,420 employer-sponsored arrivals from to the second top temporary source country in Medicine dominated, with the scale of health workforce loss not an issue of concern to the Indian government 197. In 2006, according to the Census, 1,121 Indian doctors, 639 nurses, 84 dentists and 219 other allied health professionals were resident who had arrived in the previous 5 years. Counting all vintages of migration, 5,094 Indian health professionals were living in Australia at this time, in rank order: Doctors: 2,743 Nurses: 1,458 Dentists: 221 Other allied health professionals: 672 Indian health professionals labour market integration rates were very positive - far exceeding those achieved in Canada (where 19% of doctors in 2001 found medical work in their first 5 years, compared to 66% in Australia) 198. In terms of medicine 73% of arrivals were professionally employed by 2006 (61% in medicine and the remainder in other fields). No Indian doctors reported taking low skilled work. It is important to note however that 7% were unemployed, while 19% were categorized as not in the labour force in Significant AMC barriers were also experienced: MCQ pass rate (1978 to 2010): 51% (3,183 out of 6,241 candidates) MCQ pass rate ( ): 52% Clinical pass rate (1978 to 2010): 56% (1,600 out of 2,870 candidates) Competent Authority pathway ( ): India 3rd top source of candidates from (575 applications, translating by 2010 to 290 Advanced Standing Certificates and 422 AMC Certificates) Scale of specialist assessments ( ): 2,712 applications (second top source country) Specialist assessment outcomes ( ): 61% of Indian qualifications deemed substantially or partially comparable Employment findings were more mixed in the other two fields assessed. Outcomes for nursing/ midwifery were impressive: Employment outcomes for arrivals (2006 Census): 81% employed (including 72% in nursing and 9% in lower skilled work), 2% unemployed, and 17% not in the labour force ANMAC pre-migration assessment : Ranked top country of application (2,437) noting no recognition outcomes by source country were made available ANMAC pre-migration application rates 2010: 453 from India 121

123 Outcomes for recent dental migrants by contrast were poor: Employment outcomes for arrivals (2006 Census): 45% employed (just 23% in dentistry, 5% in other professions and 18% in lower-skilled work), 11% unemployed, and an extraordinary 44% not in the labour force ADC pre-migration assessment : No country of application data made available Interestingly, the OET represented a significant barrier for Indian health professionals. Just 21% passed the exam on their first attempt in 2005 (when passes on the 4 sub-tests over repeat sittings were allowed), while 31% passed overall. By % passed on their first attempt, with 43% securing an ultimate pass on a single sitting. Language testing thus constituted a serious labour market barrier for future health professionals. As noted, emigration trends could solely be sourced for all health fields combined. From to India was the 14th top country of emigration (116 people, many of whom would have arrived on a temporary sponsored basis). The numbers leaving in were just 31 (1% of the annual total). 6.6 Malaysia For many years Malaysia has been Australia s primary source of international medical and allied health students large numbers of whom remain through the study-migration pathway (by 2005 the source of around half of all GSM migrants). For international students with Australian health qualifications the pathway is clear. They migrate with full vocational registration, are exempted from English language testing, and are highly acceptable to Australian employers. As will be demonstrated in Section 7, by December 2009 there were 2,240 Malaysian students enrolled in Australian medical and allied health degrees Australia s third top source, following Singapore and China. The majority were qualifying in medicine ( entry to practice [EP] courses for school leavers or graduate entry degrees). The next most popular field was nursing (161 Malaysian students enrolled in baccalaureate degrees, and 223 in diploma to degree post-basic conversion courses). Within this context, Australia has a longstanding dependence on Malaysia for health workforce migration. From to Malaysia was the source of 1,470 GSM health-qualified migrants, in , ranked third overall. The scale of 457 visa arrivals was slightly greater, with a total of 1,570 employer-sponsored migrants from to the fourth top temporary source country in Medicine again dominated large numbers of those selected being former international students seeking Australian internships as a pre-condition for skilled migration. In 2006, according to the Census, 171 Malaysian doctors, 151 nurses, 28 dentists and 205 other allied health professionals were also resident who had arrived from Malaysia in the previous 5 years. Unlike former students they had qualified outside Australia. Counting all vintages of migration, Malaysian health professionals were living in Australia at this time (in rank order) included: Doctors: 2,408 Nurses: 2,915 Dentists: 469 Other allied health professionals: 1,

124 Malaysian health professionals labour market integration rates were strong, reflecting their onshore as well as offshore qualification status. In terms of medicine 67% were professionally employed by 2006 (62% in medicine and 5% in other professional fields). No Malaysian doctors reported taking low skilled work. Just 3% were unemployed, though 30% were categorized as not in the labour force (likely to be those who had qualified offshore). Few were obliged to take the AMC pathway: MCQ pass rate (1978 to 2010): 58% (153 out of just 263 candidates) Clinical pass rate (1978 to 2010): 59% (41 out of just 70 candidates) Competent Authority pathway ( ): Malaysia not ranked in the top countries of training Scale of specialist assessments ( ): Ditto Specialist assessment outcomes ( ): Ditto Employment findings were similarly positive in the other two fields assessed. Key findings for nursing/midwifery were as follows: Employment outcomes for arrivals (2006 Census): 76% employed (including 64% in nursing and 12% in lower skilled work), 6% unemployed, and 18% not in the labour force ANMAC pre-migration assessment : Malaysia not ranked in the top countries of training ANMAC pre-migration application rates 2010: Ditto Labour market integration rates for dental migrants were also impressive: Employment outcomes for arrivals (2006 Census): 76% employed (64% in dentistry, and 12% in lower-skilled work), 6% unemployed, and 18% not in the labour force (comparable to ESB rates) ADC pre-migration assessment : No country of application data made available Reflecting their onshore migration pathway the OET represented an insignificant barrier for Malaysian candidates, with Malaysia not listed as a major source of candidates. Modest rates of emigration prevailed. From to Malaysia was the 7th top country of emigration (185 people or 15% of the annual total). It was not possible to assess the proportion who were former international students. 6.7 China Australia has a growing dependence on China for health workforce migration. From to it was the source of 1,030 GSM health-qualified migrants, in ranked 4 th overall. The scale of 457 visa arrivals was greater, with a total of 1,380 employer-sponsored arrivals from to the fifth top temporary source country in According to OECD research, as in India out-migration was not an issue of concern to the Chinese government 199. In 2006, according to the Census, just 57 doctors, 471 nurses, 14 dentists and 109 other allied health professionals from China were resident who had arrived in the previous 5 years. Counting all vintages of migration, 3,200 Chinese health professionals were living in Australia at this time, in rank order: Nurses: 1,

125 Doctors: 673 Dentists: 133 Other allied health professionals: 963 Health professional migration from China has recently been increasing however. From to ,030 health professionals from China were selected as primary applicants under the GSM program (360 in ), while an additional 1,380 were sponsored on 457 temporary visas (290 in ). Chinese health professionals early labour market integration rates were relatively poor (directly comparable to outcomes in Canada) 200. While 53% of medical arrivals were working by 2006, just 6% had positions in medicine compared to 47% in other fields. Eleven percent were unemployed at this time, while 36% were categorized as not in the labour force. While reasonable AMC outcomes were achieved, these often took time: MCQ pass rate (1978 to 2010): 49% (781 out of 1,587 candidates) MCQ pass rate ( ): 58% Clinical pass rate (1978 to 2010): 61% (517 out of 843 candidates) Competent Authority pathway ( ): China not ranked in the top countries of training Scale of specialist assessments ( ): Ditto Specialist assessment outcomes ( ): Ditto Chinese migrants professional access was significantly better in nursing/ midwifery, as follows: Employment outcomes for arrivals (2006 Census): 69% employed (including 53% in nursing and 15% in lower skilled work), 5% unemployed, and 27% not in the labour force ANMAC pre-migration assessment : Ranked third top country of application (1,316) noting no recognition outcomes by source country were made available ANMAC pre-migration application rates 2010: 421 from China a recent surge in applications being experienced as is also the case with India Outcomes for recent dental migrants were much worse: Employment outcomes for arrivals (2006 Census): 54% employed (just 21% in dentistry, 11% in other professions and 21% in lower-skilled work), nil unemployed, but an extraordinary 46% not in the labour force (noting relatively low numbers here just arrivals in all) ADC pre-migration assessment : No country of application data made available Unsurprisingly, the OET represented a significant barrier for Chinese health professionals. Eighteen percent passed on their first attempt in 2005 (when passes on the 4 sub-tests over repeat sittings were allowed), while 26% passed overall. By % passed on their first attempt, with 39% securing an ultimate pass on a single sitting. Language testing constitutes a serious labour market barrier, though interestingly the analysis found minimal difference in outcomes for India (a country associated with far greater English language exposure). From to China s emigration rate was relatively high (the 5th top country of emigration, with 450 people). The numbers leaving in were 104 (4% of the annual total). 124

126 6.8 Philippines Over-Production for Export As noted for China and India, migration source countries have very diverse attitudes in relation to health workforce out-migration: Some governments are deeply concerned at emigration and seek to minimise it (for example Singapore, South Africa and Malawi 201 ). Some maintain laissez-faire policies (like India and China), with regulatory mechanisms progressively liberalised. In India, for example, the government has signed MOU s to facilitate labour mobility with a wide range of countries, including bilateral agreements with six Middle Eastern nations to provide private and government doctors on short term assignments 202. A third government strategy involves what might be termed over-production for export the policy adopted by the Philippines, one of the world s largest health worker sending countries, with an estimated 9 million migrants currently generating remittances overseas (all fields). Within the export-production model the state is a key player, supported by a vast network of private recruitment agencies which broker out-migration a major focus in the Philippines being nurses. The country has long exported female labour, with women by 1987 constituting some 83 per cent of all Asia-bound migrants. As early as 1985 and 1987 alone, 65,940 Filipino nurses were employed overseas - a conservative estimate, since this excluded nurses leaving the Philippines under family, business and other emigration categories. For employed nurses the goal was improved work conditions and rewards, compared to chronic overwork, poor security in remote hardship posts, and lack of opportunity for growth and development. So great was this nurse exodus that by 1989 some 11% of Filipino hospital and public health positions were vacant, with the quality of nurse education compromised by the number of nurse academics and deans leaving. According to one analyst, there were severe consequences for the quality of health service provision in the Philippines: Despite the lack of qualified nursing deans and faculties, more nursing colleges are opening due to increased demand. Nursing schools have become such a lucrative business that politicians, businessmen and even parents pressured the Department of Education, Culture and Sports to lift the moratorium on opening new schools of nursing. Thus, the conditions prevailing in nursing schools remain deplorable. In 1988, about half of the schools did not meet the standards set by (the government). Students graduate with little clinical exposure or experience 204. By some 152,741 students were enrolled in Filipino nursing schools (the second most popular field after engineering). The consequence was a country 'awash with unemployed and underemployed nurses waiting for a ticket abroad', with access to paid positions almost impossible to find for those lacking contacts, or trained in the less prestigious institutions 205. By 2007 the Philippines had a stock of 332,206 nurses, with jobs for just 29,467. These nurses had trained in 441 nursing colleges of variable quality (compared to 40 three decades before). 163,756 Filipino nurses were employed overseas at this time, joined annually by around 3,500 doctors migrating as nurse medics 206. By ,743 Filipino students were enrolled in medical and allied health courses the great majority in private sector export-oriented institutions, targeting the US, Saudi Arabia, the United Arab Emirates, Canada and Australia as employment destinations. 125

127 Filipino Health Workers in Australia From to the Philippines was the source of 570 GSM health-qualified migrants to Australia, in ranked 7th overall. The scale of 457 visa arrivals however was vastly greater, with a further 1,850 employer-sponsored arrivals from to the sixth top temporary source country in In 2006, according to the Census, 176 Filipino doctors, 766 nurses, just 6 dentists and 41 other allied health professionals were resident who had arrived in the previous 5 years. Counting all vintages of migration, however, 4,638 Filipino health professionals were living in Australia at this time, with nurses massively dominant: Nurses: 3,977 Doctors: 380 Dentists: 53 Other allied health professionals: 228 Filipino health professionals labour market integration rates were mixed. In terms of medicine 77% were professionally employed by 2006 (50% in medicine and the remainder in other fields). No Filipino doctors reported taking low skilled work. Just 5% were unemployed, while 19% were categorized as not in the labour force. AMC barriers, however, were found to be formidable: MCQ pass rate (1978 to 2010): 31% (639 out of 2,056 candidates) MCQ pass rate ( ): 34% Clinical pass rate (1978 to 2010): 38% (260 out of 689 candidates) Competent Authority pathway ( ): Not listed in the top 10 countries of training Scale of specialist assessments ( ): 152 applications (10 th top source country) Specialist assessment outcomes ( ): Just 39% of Filipino qualifications deemed substantially or partially comparable Employment findings were variable for the other two fields assessed. Key findings for nursing/ midwifery were as follows: Employment outcomes for arrivals (2006 Census): 77% employed (including 58% in nursing and 19% in lower skilled work), 2% unemployed, and 21% not in the labour force ANMAC pre-migration assessment : Ranked fourth top country of application (957) noting again no recognition outcomes by source country were made available ANMAC pre-migration application rates 2010: 266 from the Philippines Outcomes for recent dental migrants were far poorer: Employment outcomes for arrivals (2006 Census): 63% employed (noting a meagre 7% in dentistry, 3% in other professions and 53% in lower-skilled work), 9% unemployed, and 27% not in the labour force ADC pre-migration assessment : No country of application data available As we have seen, the OET represented a very significant barrier for Filipino health professionals. Twenty-seven percent passed on their first attempt in 2005 (when passes on the 4 sub-tests over repeat sittings were allowed), with 37% passing overall. By 2010 just 14% passed on their first attempt, with 24% securing an ultimate pass on a single sitting. These outcomes reflect the low pass rates for nurses overall (19%). 126

128 From to the Philippines was the 9th top country of health workforce emigration (159 people, many of whom would have arrived on a temporary sponsored basis). The numbers leaving in were just 29 (1% of the annual total). Australia was more likely to lose migrants who encountered minimal employment barriers. 6.9 Iran/ Iraq (Other Southern and Central Asia) The previous eight case studies focus on established health professional source countries for Australia. Flows from Iran and Iraq are small. How do these relatively new groups fare in terms of labour market integration? From to Iran ranked 16 th in the top 20 source countries for GSM migration to Australia (110 arrivals), and 14 th for 457 visa flows (540). Iraqis arrive through refugee flows, category typically dominated by the low-skilled. As the summary to follow demonstrates however, Iraq and Iran trained doctors and nurses fare comparatively well. In 2006, according to the Census, 364 doctors, 51 nurses, and 24 dentists were resident who had arrived from Southern and Central Asia in the previous 5 years (predominantly Iran and Iraq). In terms of medicine 53% were professionally employed by 2006 (an impressive 43% in medicine and the remainder in other fields). No doctors reported taling low skilled work. Just 7% were unemployed, but 40% were categorized as not in the labour force (certain to be preparing to address pre-registration barriers). AMC results were impressive reported first for Iran in a context where it is worth noting these candidates outperformed India-qualified doctors: MCQ pass rate (1978 to 2010): 60% (726 out of 1,204 candidates) MCQ pass rate ( ): 56% Clinical pass rate (1978 to 2010): 65% (314 out of 484 candidates) Competent Authority pathway ( ): Not ranked in the top 20 source countries Scale of specialist assessments ( ): 205 applications (ranked as the 8 th top source country) Specialist assessment outcomes ( ): 51% of qualifications deemed substantially or partially comparable The AMC results for Iraq-trained doctors were highly comparable (noting this was not a top ranked country for specialist pathways): MCQ pass rate (1978 to 2010): 65% (586 out of 895 candidates) MCQ pass rate ( ): 52% Clinical pass rate (1978 to 2010): 60% (371 out of 623 candidates) Competent Authority pathway ( ): Ranked the 9 th top country of training (48 applicants), with 30 Advanced Standing Certificates issued and 18 AMC certificates Employment findings were similarly strong in relation to nursing (examined in the Census for Iraq and Iran combined). Key outcomes were as follows: Employment outcomes for arrivals (2006 Census): 65% employed (including 59% in nursing and 6% in lower skilled work), 6% unemployed, and 29% not in the labour force ANMAC pre-migration assessment : Not ranked in the top 20 source countries for pre-migration assessment ANMAC pre-migration application rates 2010: Ditto 127

129 Outcomes for recent dental migrants were far poorer: Employment outcomes for arrivals (2006 Census): Just 17% employed (nil in dentistry, and 17% in lower-skilled work), 13% unemployed, and 71% not in the labour force (noting just 24 dentists were involved) ADC pre-migration assessment : No country of application data available The Occupational English Test represents a significant hurdle for Iraqi and Iranian health professionals - prelude to their impressive AMC outcomes. Thirty-one percent of Iraqis passed on their first attempt in 2005 compared to 32% of Iranians, while 46% passed overall (compared to 44%). By % of Iraqis passed on their first attempt (compared to 23% of Iranians), while 43% secured an ultimate pass on a single sitting (compared to 33%). Unsurprisingly, from to Iran and Iraq did not feature in the top countries of emigration for health professionals. On the basis of the above findings, they represent a valuable medical and nursing workforce resource for Australia Egypt The final case study examines the scale and outcomes of recent Egyptian flows to Australia most notable in medicine and pharmacy. From to Egypt was the 11 th top source country for GSM migration to Australia, rising to the 5 th top GSM source by (190). (It did not rank in the top 20 sources for 457 visas.) As demonstrated in Section 5, Egypt has become a major recent source of pharmacy applicants the Australian Pharmacy Council reporting it to be the top country of training for stage 1 APC eligibility assessments in (38% of candidates), and the primary source for stage 11 assessment (a high 52%) in each case followed by India 207. In 2006, according to the Census, 564 doctors, 172 nurses, and 128 dentists were resident in Australia who had arrived from North Africa and the Middle East in the previous 5 years (Egypt being the major source country). In terms of medicine 60% were professionally employed by 2006 (47% in medicine and the remainder in other fields). No doctors reported taking low skilled work. Ten percent were unemployed, while 31% were categorized as not in the labour force (certain to be preparing to address pre-registration barriers). AMC results were average for Egyptian candidates: MCQ pass rate (1978 to 2010): 41% (825 out of 1,990 candidates) MCQ pass rate ( ): 52% Clinical pass rate (1978 to 2010): 44% (541 out of 1,230 candidates) Competent Authority pathway ( ): Not ranked in the top 10 countries of training Scale of specialist assessments ( ): Not ranked in the top 10 countries of training Employment findings were very modest in nursing/midwifery as follows: Employment outcomes for arrivals (2006 Census): 40% employed (including 33% in nursing and 7% in lower skilled work), 5% unemployed, and an extraordinary 55% not in the labour force ANMAC pre-migration assessment : Not ranked in the top 20 source countries for pre-migration assessment ANMAC pre-migration application rates 2010: Ditto 128

130 Outcomes for recent dental migrants were better: Employment outcomes for arrivals (2006 Census): 58% employed (44% in dentistry, 2% in other professions and 12% in lower-skilled work), 9% unemployed, and 33% not in the labour force ADC pre-migration assessment : No country of application data available The OET however represented a severe barrier for Egyptian health professionals, particularly in Thirty-seven percent of candidates passed on their first attempt in 2005, while 49% passed overall. By 2010 however just 19% of Egyptian candidates passed on their first attempt, while 29% secured an ultimate pass on a single sitting. This was one of the worst outcomes. From to Egypt did not feature in the top 20 countries of emigration for health professionals Key Findings The Ethics of Health Worker Recruitment There is now growing debate on the ethics of health workforce recruitment - the subject of seminal recent World Health Organisation and OECD studies 208. In relation to this it is worth noting Australia currently imports large numbers of health professionals who are professionally displaced. Within this context two issues are relevant. The first concerns the ethics of recruiting from developing countries, in a context where multiple models of compensation have been attempted (for example by the UK), but with limited effectiveness to date 209. The second concerns the need to make use of the skills imported, rather than allow them to waste a social justice as well as an efficiency imperative. According to one recent analyst: Australia, unlike the UK, has not developed its Code of Practice for International Recruitment and to date has not explicitly accepted the principle of mutuality of benefits. The net inflow of medical practitioners and nurses into Australia represents a considerable savings in training costs to the Australian government, what some have called a perverse subsidy (However) While development aid is given to some poorer source countries there is no direct link with health care systems 210. Recognition and Employment in Australia It is beyond the brief of this paper to address the ethics of health workforce migration. As demonstrated however, migrant health professionals derived from English speaking background and Commonwealth countries secure very positive early labour market integration rates in Australia. They share two advantages high exposure to English and training in British-origin education systems. This finding stands despite select exceptions, such as the relatively poor outcomes experienced by Indian dentists in their first 5 years. Health professionals derived from non English speaking background and/ or non-commonwealth countries perform less well, despite mobility clearly improving within 10 or more years (a finding confirmed by analysis of 2006 Census outcomes for pre-1996 and migrant arrivals.) Medical professionals from China and Vietnam are exemplars of this trend, noting Australian medical employment rates typically rise from an exceedingly low base to around 80% after 10 or more years 211. Large numbers of such NESB health professionals face years of professional displacement and skills atrophy. Many never achieve appropriate work. Within this period most will seek Australian English and/or vocational training support (for example while completing 129

131 elongated AMC pathways the outer limit of exam attempts defined by the 2007 DoHA commissioned study being 16 years). Beyond country of training, immigration category significantly influences employment outcomes. GSM primary applicants fare significantly better than family and humanitarian category migrants, given the filtering of their human capital attributes through mandatory English language testing and pre-migration credential assessment. Unemployment or professional displacement is not an issue for 457 temporary visa applicants, who by definition arrive with offers of work. Given the Australian Health Ministers goal by 2025 is domestic self-sufficiency, immigration category and country of training are thus significant policy issues, should Australia wish to secure migrants able to maximise their contribution in the coming decade. 130

132 Section 7: International Students as a Health Workforce Resource 7.1 International Students and Skilled Migration the Policy Context The Rise of the Study-Migration Pathway Australia has a further health migration resource former international students, who have selffunded to meet Australian employment requirements. By definition former students are characterised by: Youth (the 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 or allied health vocational registration Significant acculturation Training to Australian professional norms (including regional as well as urban rotations) In 1999, following the removal of a three year eligibility bar, international students became immediately able to migrate to Australia. Within a year of the policy change, around 50% of GSM applicants held local degrees. From 2002 former international students were permitted to apply onshore - ideally placed to secure the requisite points if they possessed a recognised vocation-related degree (60 points 212 ), were aged between 18 and 29 years (30 points), had advanced English language ability (20 points, with testing exempted), and an Australian qualification of 2 years in a field in a high priority field (until 2010 defined by the former Migration Occupations in Demand List or MODL). In ,000 international students were enrolled in Australian courses - the majority ethnic Chinese from Commonwealth-Asian countries, including very substantial numbers drawn to twostep migration. By the time of Australia s 2006 skilled migration review, students applying to migrate had a 99% chance of being selected, unless failing health or character checks 213. Scope for GSM migration had fuelled the development of new international student markets (primarily China and India), while transforming the sector and discipline of demand. Within this decade, Australia s migration and export education programs had become inextricably linked, representing a potential win-win for Australia. 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 Victoria 214. In August that year 474,389 international students were enrolled in Australian tertiary, vocational, English language or school courses, including substantial numbers located offshore. 432,678 international students were resident in Australia at this time. Students from China (28%) and India (17%) dominated, in a context where around 66% of Indian and 38% of Chinese students would ultimately migrate, and there was minimal growth in demand from Australia s traditional Commonwealth Asian source countries 215. Global Trends in Student Migration By June 2009 international student were profoundly influencing Australia s net population growth 216. According to an Oxford based migration researcher: 131

133 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) 217. The phenomenon of two-step student migration is one proliferating world-wide. The majority of OECD countries are in the process of: Developing migration categories designed to attract and retain skilled workers; Monitoring and replicating successful competitor models, including mechanisms for selection and control; Expanding temporary entry options, targeting international students and employersponsored workers; Facilitating student and worker transition from temporary to extended or permanent resident status, supported by priority processing and uncapped migration categories; Combining government-driven with employer-driven strategies; Creating regional settlement incentives designed to attract skilled migrants, supported by lower entry requirements and policy input from local governments and/or employers; and Supporting the above strategies through sustained and increasingly innovative global promotion strategies 218. Transitioning to Permanent Residence - Onshore GSM Applications in Australia (All Fields) In % of GSM primary applicants to Australia were approved onshore (12,215 people), compared to 35% in Former international students dominated. The top 5 source countries for students securing permanent residence at this time were China (28%), India (17%), Republic of Korea (6%), Malaysia (5%) and Indonesia (5%) countries of training (as we have seen) associated with highly variable outcomes for migrant health professionals trained offshore. By ,552 international students were enrolled in Australian courses 231,639 in the vocational sector compared to 202,229 in higher education. While VET sector enrolments have recently plummeted 20% (following the introduction of measures to address perverse studymigration incentives), higher education enrolments have continued to climb - by 16% in the year to March 2011, levelling to 2% to July International Enrolments in Australian Medical and Allied Health Degrees The Scale of International Student Demand for Australian Degrees In 2010, according to a recent Deloitte study, 242,711 international students were enrolled in Australian university courses including 139,902 in bachelor degrees, 80,935 in masters degrees, and 13,355 in doctoral courses. Commencements in health have continued to rise, from 6,255 in 2008 to 6,993 in 2010, yielding 18,487 total enrolments (8% of Australia s higher education sector) 219. The study-migration pathway has become a major health workforce resource for Australia, in particular in the fields of medicine and nursing. Enrolments are likely to intensify, as Federal policy shifts to high calibre students in tertiary courses, rather than students trained in poor quality education providers operating for profit on migration rather than education outcomes

134 In December ,772 international students were enrolled in entry to practice (EP) medical degrees (pre-vocational courses based on school-leaver or graduate entry) compared to 963 in By semester , enrolments had grown to around 3,000. (See Table 39 for enrolment growth by select field.) An estimated 70% of former international students secure Australian internship training on completion of their degrees, with interest strongest from those born in South East Asia (mainly Malaysia and Singapore), the Middle East and Africa Demand from North American students is also rapidly growing. Table 39: Growth in Undergraduate International Student Enrolments in Australian Universities in the Medical/Health Sciences: Field % Change % Change Dental science % 295% EP Medicine % 188% Medical science % 2346% Public health No data n/d % n/d Nursing (basic) % 704% Nursing (post-basic) % 371% Physiotherapy % 362% Psychology % 424% Social Work % n/d Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). This pattern applies to a range of additional fields. Increased numbers of dental graduates are retained in Australia, in a context where 387 international students were enrolled in dental degrees by Australia s mass international market to date however is for basic and postbasic undergraduate nursing courses. 762 international students were enrolled in baccalaureate nursing degrees in 1996, rising to 6,124 by The demand for post-basic (PB) diploma to degree conversion courses rose from 545 to 2,566 at this time one to two year options of particular interest to migration-motivated nurses, first qualified in India and China. Top International Student Source Countries With the exception of Canada, medical and allied health international students to date have largely been derived from Asia. As demonstrated by Table 40 (based on the latest available DEEWR data), 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 Australia s primary student sources for health sector degrees (these data excluding pharmacy). The main international source countries by qualification field were: 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). 133

135 Table 40: Trends in International Student Demand for Australian Medical and Allied Health Courses by Major Source Countries (2009) Course Sing Chi Mal Ind S Kor Can HK Jap Indo US Viet Taiw Thai Nor Level UG dent PG dent EP med PG med UG nurs Pb nurs PG nurs UG phys PG phys UG pubh UG psych PG psych UG soc wk PG soc wk No No No No No No No Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). 7.3 Source Countries and Training Institutions From to ,400 registered nurses were selected by Australia as primary GSM applicants. In % of these nurses had converted their status onshore, compared to just 16% in (the majority through the study-migration pathway). In % of other allied health professionals (including dentists, pharmacists and physiotherapists) were accepted onshore by DIAC, comparable to 5 years earlier. (See Table 15 in Section 2.) Identical trends apply in other fields. For example by two-thirds of GSM engineering migrants had qualified in Australia, compared to just a third 5 years earlier in Tables detail Australia s top 10 source countries for international students enrolled in Australian dental, medical and nursing degrees, comparing 2009 with In terms of nursing (Table 41), the focus is on enrolments in post-basic nursing degrees. These courses are particularly favoured by international nurses hoping to convert offshore diploma qualifications in order to qualify for GSM migration at speed. 134

136 Table 41: Top 10 Source Countries for UG and PG International Students in Australian Dental Science Courses (2000 and 2009) UG Dental Science Students (2000: 124) UG Dental Science Students (2009: 387) 1. Malaysia (40) 1. Malaysia (99) 2. Singapore (29) 2. Singapore (79) 3. Canada (9) 3. S Korea (58) 4. Mauritius (4) 4. Canada (55) 4. Fiji (4) 5. China (22) 4. HK (4) 6. Indonesia (11) 4. Taiwan (4) 7. Taiwan (9) S Korea, Nepal and Vietnam (3 each) 8. Hong Kong (8) 9. Not Known (7) 10. Mauritius (5) Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). Table 42: Top 10 Source Countries for UG and PG International Students in Australian Medicine Courses (2004 and 2009) Entry to Practice Medicine Students (2004:1505) (Graduate and School Leaver Entry) Entry to Practice Medicine Students (2009: 2772) (Graduate and School Leaver Entry) 1. Malaysia (536) 1. Malaysia (1134) 2. Singapore (232) 2. Singapore (577) 3. Canada (160) 3. Canada (437) 4. USA (87) 4. USA (84) 5. Norway (79) 5. Botswana (74) 6. Indonesia (50) 6. Brunei (51) 7. Hong Kong (46) 6. South Korea (51) 8. Botswana (39) 8. Hong Kong (50) 9. Taiwan (34) 9. Indonesia (40) 10. Mauritius (23) 10 Sri Lanka (31) Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). Table 43: Top 10 Source Countries for UG Post-Basic and PG International Students in Australian Post-Basic Nursing Courses (2000 and 2009) UG Post-Basic Nursing Students (2000: 2336) UG Post-Basic Nursing Students (2009: 2566) 1. Hong Kong (1,330) 1. Singapore (1188) 2. Singapore (514) 2. China (224) 3. Malaysia (185) 3. Malaysia (223) 4. Canada (107) 4. India (208) 5. Zimbabwe (46) 5. UAE (202) 6. China (21) 6. Nepal (112) 7. UAE (16) 7. South Korea (74) 8. Taiwan (13) 8. Japan (35) 9. Fiji (9) 8. Somalia (35) 10. India (7) 10. Philippines (29) Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). 135

137 Table 44: Top 10 Source Countries for UG and PG International Students in Australian Physiotherapy Courses (2000 and 2009) UG Physiotherapy Students (2000: 173) UG Physiotherapy Students (2009:365) 1. Singapore (28) 1. Singapore (104) 2. South Korea (24) 2. South Korea (57) 3. Canada (20) 3. Malaysia (46) 4. Norway (18) 4. Hong Kong (35) 4. Hong Kong (18) 5. China (27) 6. Malaysia (11) 6. Norway (7 ) 7. USA (8) 6. Taiwan (7) 8. Botswana (6) 6. Canada (7) 8. Japan (6) 9. Mauritius (6) 10. India and Taiwan (4 each) 10. India & Zimbabwe. (5 each) Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). Location of International Student Enrolments by Major Institution International student enrolments vary significantly by state and institution, with Tables defining the major training institutions by field for medicine, nursing and dentistry (2009). Victoria, for example, has trained exceptional numbers of international medical students in recent years, in a context where export education has emerged as the state s primary industry, and Monash and Melbourne have developed strong international student flows (constituting up to 27% of the student body). Dramatic recent expansion has occurred at the University of Queensland, most notably in relation to medical students derived from Canada and the US. (For example in semester Canadian students commenced the University of Queensland graduate entry medical degree.) Victoria, Queensland, NSW and Western Australia have been the major Australian states to engage in international nurse student training, with the Australian Catholic University (26% of basic nursing enrolments), Queensland University of Technology (10%) the University of Western Sydney and Deakin University (8%) being particularly prominent here. (Please note a substantial number were enrolled offshore by distance.) Table 45: Top Institutions of Training for International Students Enrolled in Australian Entry to Practice Medical Courses (2009) Institution University (Total) University (%) Monash % Melbourne % Queensland % UNSW % Sydney 179 6% Adelaide 168 6% All Other % Total 2, % Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). 136

138 Table 46: Top Institutions of Training for International Students Enrolled in Australian Basic Undergraduate Nursing Courses (2009) Institution University (Total) University (%) ACU 1,569 26% QUT % UWS 503 8% Deakin 480 8% Flinders 356 6% South Australia 344 6% All Other 2,261 37% Total 6, % Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). Table 47: Top Institutions of Training for International Students Enrolled in Australian Post-Basic Undergraduate Nursing Courses (2009) Institution University (Total) University (%) Griffith % Curtin % La Trobe % ACU % Sydney % Monash 107 4% All Other % Total 2, % Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). Table 48: Top Institutions of Training for International Students Enrolled in Australian Undergraduate Dental Courses (2009) Institution University (Total) University (%) Melbourne % Adelaide 94 24% UQ 53 14% Sydney 48 12% UWA 23 6% Griffith 9 2% All Other 2 1% Total % Source: Analysis by L Hawthorne, A Langley, A To & A Song of DEEWR international student enrolment data, medical and allied health courses (February 2011). 137

139 7.4 Skilled Migration Outcomes for Former International Students Internship Access - The Bridge to Skilled Migration for International Medical Students For international medical students internships represent a critical bridge to migration. On graduation they must secure 457 visas supported by hospital sponsorship to remain. Following successful completion of the postgraduate training year, they become eligible to migrate. As stated by a NSW key informant, however, competition for Australian clinical places is rapidly accelerating. While domestic graduates are guaranteed placement, there is no such certainty for international students or indeed IMGs: What s looming on the horizon is the alleged tsunami of local medical graduates. All states have taken off the register for intern allocations people who are going through the AMC, which means even if they do both parts of the AMC they may not be able to get vocational registration because they may not be able to do their year of supervised practice, which causes us some concerns The other issue is support for IMG s who do both parts of the AMC in their intern year. They re often pretty bloody awful at the start of their intern year. They often haven t done what our graduates have done, sitting round in the hospital for the past few years, because they ve been studying for their exams, trying to keep their family together and things like that. (Despite some scattered initiatives) there is not much going on overall. They need good support, so when they start their internship on the first day they re in reasonable condition. Given the scale of growth in domestic medical student demand for internships, international medical students now express considerable anxiety on this score. In % of international medical students qualified in Australia secured internship offers for the following year, of the very large numbers applying. In 2010, while no international students were awarded NSW first round offers, all were ultimately placed for the following year (reportedly 6 positions remaining unfilled after this process) 223. The situation for 2012 and beyond however is unclear. The Recent Scale of Migrant Health Professionals Qualified in Australia (CSAM) In , as noted, a total of 15,590 temporary migrants converted to General Skilled Migration status onshore (these outcomes based on all fields). By this number had risen 39,170, including large numbers of former international students qualified in nursing and medicine. Analysis of Australia s Continuous Survey of Australia s Migrants data for migrants approved in 2008 and 2009 provides insight on the scale of international student recruitment in select health professions. As demonstrated by Table 49 2,570 GSM and family category health professionals in the sample held Australian qualifications (49% of the total), compared to 2,640 qualified overseas. The scale of onshore training differed significantly by field, as follows: Medicine: 520 GSM and family category migrants with Australian qualifications (65% of the total, compared to 270 migrants selected offshore) Nursing: 1,090 GSM and family category migrants with Australian qualifications (47%, compared to 1,230 migrants selected offshore) Dentistry: 30 GSM and family category migrants with Australian qualifications (21%, compared to 100 migrants selected offshore) Physiotherapy: 100 GSM and family category migrants with Australian qualifications (an extraordinary 71%, compared to 40 migrants selected offshore) Pharmacy: 170 GSM and family category migrants with Australian qualifications (63%, compared to 110 migrants selected offshore) 138

140 Table 49: Employment Status of Skilled and Family Primary Applicants by Australian Qualification and Grant Location (for Migrants Selected March 2008 to October 2009) Employment Outcome & Profession Employment Status Australian qualification No Australian Qualification Total Offshore Onshore Total Offshore Onshore Total Offshore Onshore Total No. No. No. No. No. No. No. No. No. Employed All Health Professions Full time 380 1,900 2, ,250 2,160 1,290 3,150 4,440 Part time Total 450 2,120 2,570 1,190 1,450 2,640 1,640 3,560 5,200 Medicine Full time Part time Total Nursing & Midwifery Full time , ,590 1,990 Part time Total , , ,800 2,320 Dentistry Full time Part time Total Physiotherapy Full time Part time Total Pharmacy Full time Part time Total Other Allied Health Full time ,250 Part time Total ,030 1,540 All Other Professions Full time 1,820 10,650 12,470 8,360 11,070 19,430 10,180 21,750 31,930 Part time 580 4,350 4,930 2,810 3,000 5,810 3,400 7,350 10,750 Not Known , ,270 2,120 Total 2,500 15,620 18,110 11,920 14,730 26,650 14,420 30,340 44,800 Unemployed 770 1,210 1,980 4,870 1,550 6,420 5,660 2,760 8,410 Not working/nilf(a) ,100 8,780 3,310 12,080 9,100 4,280 13,380 Total 3,970 19,800 23,770 26,750 21,030 47,780 30,720 40,830 71,790 (a) NILF - Not in the Labour Force Note 1: Figures have been rounded to the nearest 10 Source: Unpublished CSAM data provided to HWA by the Department of Immigration and Citizenship (2011). The Impact of Age and Immigration Category on Outcomes Analysis of the CSAM confirmed migrant health professionals selected onshore were significantly younger than those offshore a finding with marked implications for long-term productivity. From March 2008 to October % of former students selected were aged years, compared to 28% of offshore migrants (51% of the latter aged years, and 21% aged 41 years or over). Age is highly significant to migrants professional registration outcomes and employment. For example 83% of overseas-trained candidates passed the Australian Medical Council MCQ on one or successive attempts if attempted within 4 years of graduation. This dropped to a pass rate of just 68% for candidates qualified 20 years or more. (See Section 4.) Immigration category is also highly significant to employment outcomes. As demonstrated in Section 2 (again based on CSAM data), GSM health professionals had very strong employment rates in 2009 and 2010, with negligible numbers unemployed or not in the labour force. Family category migrants by contrast had dramatically higher unemployment and not in the labourforce rates. (See Table 18, replicated here for ease of reference.) 139

141 Table 18: Employment Outcomes and Profession of Primary Applicant by Field for Health Professionals Selected by Skilled Compared to Family Categories (CSAM ) No Qualification/ Employment Outcomes Health Field All Other Fields Qualification Not Stated Total & Profession Skilled Family Total Skilled Family Total Skilled Family Total Skilled Family Total No. No. No. No. No. No. No. No. No. No. No. No. Employed Health professions Medicine Nursing & Midwifery 1, , , ,320 Dentistry Pharmacy Physiotherapy Other Allied Health 1, , , ,540 All Health Professions Total 4, , , ,200 All Other professions ,060 25,620 10,480 36,100 3,030 4,600 7,630 29,140 15,650 44,790 Unemployed ,480 3,790 5, ,470 2,700 1,760 6,660 8,410 Not working/nilf(a) ,390 4,570 5, ,960 6,620 2,210 11,180 13,380 Total 4,840 2,120 6,960 28,740 18,920 47,660 4,110 13,070 17,180 37,690 34,110 71,790 (a) NILF - Not in the Labour Force Note 1: Figures have been rounded to the nearest 10 Source: Analysis of unpublished CSAM data provided by the Department of Immigration and Citizenship to Health Workforce Australia (2011). 7.5 Employment Outcomes Compared to Domestic Graduates Intention to Migrate - Medical Schools Outcomes Database and Longitudinal Tracking Project Having established these trends, we turn to assess employment outcomes by field for former international students compared to Australian domestic graduates. Minimal research has been conducted on this issue to date or indeed on the proportion of international students intending to remain in Australia through two-step migration (a workforce issue of growing significance). A potentially valuable resource is the Medical Schools Outcomes Database (MSOD) and Longitudinal Tracking Project, established by the Medical Deans of Australasia. The MSOD commenced with a pilot sample in 2005, and is currently in its third full year of administration (by definition focused solely on medical students). Regrettably, minuscule numbers of international students were included in the 2008 sample, rising to more representative numbers in recent years. (Data to date are solely available for analysis for the pilot and 2009 exit year students noting the full data set for 2010 is due for analysis late August ) Despite the limitations, the MSOD allows examination of students intention to stay, to work and to possibly migrate in the final year of study. Table 50 reports intentions for the top 10 groups of 11 As advised by Nick Kominos (August 2011), the data manager for the Medical Schools Outcomes Database and Longitudinal Tracking Project (Medical Deans Australia and New Zealand Inc.) the PGY data is still in the process of being cleaned. The data will be provided to L Hawthorne and A To at the University of Melbourne for analysis late August 2011, for a study of former international medical students early migration and career trajectories commissioned by the Medical Deans of Australasia, undertaken by the University of Melbourne and the University of Queensland. 140

142 respondents by source country, noting that Singaporean (75%), Malaysian (74%) and Canadian students (72%) were most likely to plan to remain in Australia, with 69% of all medical students hoping to do so. Table 50: Intention to Stay in Australia Following Medical Graduation (MSOD 2009) International student Domestic student Birth country other than Australia Intending to stay in Australia Not Intending to stay in Australia intending to stay in Australia Not intending to stay in Australia Persons Persons Intending to stay in Australia Not Intending to stay in Australia intending to stay in Australia Not intending Persons to stay in Australia Malaysia % % % 5 100% 0 0% 5 100% 40 Canada % % % 3 100% 0 0% 3 100% 21 India % 1 8% % 13 Singapore % % % 4 80% 1 20% 5 100% 13 New Zealand % 0 0% % 11 Brunei Darussalam % % % United States of America % % % 4 100% 0 0% 4 100% 9 United Kingdom, nfd % 0 0.0% % 7 100% 0 0% 7 100% 8 China (excludes SARs and Taiwan Province) % 0 0% 7 100% 7 Taiwan % 1 14% 7 100% 7 All other % % % 49 98% 1 2% % 66 Total Persons Grand Total Source: Analysis of MSOD database provided by the Medical Schools Outcomes Database and Longitudinal Tracking Project (June 2011), table prepared by Anna To, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne Employment Outcomes Achieved by Former International Students at Four Months (Graduate Destination Survey) The case for streamlining international students pathway is compelling, based on analysis of Australia s Graduate Destination Survey (GDS). Sourced from the University of Melbourne and analysed for the past 5 years (2006 to 2010), the GDS is based on comprehensive sample sizes, and allows assessment of: The number of former international students (by major field) remaining in Australia four months following course completion. The proportion of these students then active in the workforce. Their employment and study outcomes at 4 months, including the proportion employed full-time compared to part-time by field of qualification. The initial graduate salary levels they secured. Their acceptability to Australian employers relative to recently qualified domestic students (with comparison possible on all the above scores). This analysis has not previously been conducted for health workforce planning purposes, but the results are striking. Medicine As demonstrated by Table 51, 675 former international medical students were still resident in Australia and responded to the Graduate Destination Survey from 2006 to In % 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 % of former students resident in Australia were in the workforce. 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 141

143 graduates salaries (just $2,000-$3,000 per annum). Former international students, regardless of source country, were immediately acceptable to Australian employers Table 51: Employment Outcomes for Former International Medical Students in Australia Compared to Domestic Graduates Four Months Following Course Completion ( ) Australian citizens or Permanent Residents Non-Permanent Residents Total Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Note: The shaded rows represent a subset of those available for full-time work Source: Analysis of Graduate Destination Survey data (all Australia) by Anna To, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne (2011). 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 % 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 the 5 survey years, with outcomes for 2010 in fact 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). (See Table 52.) 142

144 Table 52: Employment Outcomes for Former International Nursing Students in Australia Compared to Domestic Graduates Four Months Following Course Completion ( ) Australian citizens or Permanent Residents Non-Permanent Residents Total Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Note: The shaded rows represent a subset of those available for full-time work Source: Analysis of Graduate Destination Survey data (all Australia) by Anna To, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne (2011). 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 % were already employed as dentists full-time, and an additional 6.3% were 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 again relatively modest. For example in % of available former students were employed in dentistry full-time, compared to 95% in 2008 and 94% in In terms of salaries at 4 months, marginally lower, comparable or higher salaries were achieved than by domestic dental graduates (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. (See Table 53.) 143

145 Table 53: Employment Outcomes for Former International Dental Students in Australia Compared to Domestic Graduates Four Months Following Course Completion ( ) Australian citizens or Permanent Residents Non-Permanent Residents Total Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Note: The shaded rows represent a subset of those available for full-time work Source: Analysis of Graduate Destination Survey data (all Australia) by Anna To, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne (2011). 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 % 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 % of international students resident in Australia were in the physiotherapy workforce, with100% 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). (See Table 54.) 144

146 Table 54: Employment Outcomes for Former International Physiotherapy Students in Australia Compared to Domestic Graduates Four Months Following Course Completion ( ) Australian citizens or Permanent Residents Non-Permanent Residents Total Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Available for full-time employment Working full-time Working part-time, seeking full-time Not working, seeking full-time In full-time study Working part-time, not seeking full-time work Not working, seeking part-time work Unavailable for work or study Total Note: The shaded rows represent a subset of those available for full-time work Source: Analysis of Graduate Destination Survey data (all Australia) by Anna To, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne (2011). 7.6 Employment Outcomes for International Medical and Allied Health Graduates Compared to All Other Fields Employment outcomes such as those above are completely atypical for former international students. In 2006 the most extensive review of Australia s skilled migration program in 20 years identified significant problems related to the study-migration pathway (all fields). First, while 83% of onshore compared to 82% of offshore skilled applicants secured Australian employment within 6 months of migration, migrants recruited offshore enjoyed superior work outcomes. Most notably, former international students were characterised by: Annual salaries of around $A33,000 (compared to $A52,500 for offshore arrivals); Average weekly earnings of $A641 (compared to $A1,015); Lower job satisfaction, (with 44% liking their work compared to 57% of offshore migrants); and Far less frequent use of formal qualifications in current work (just 46% compared to 63%) 224. A number of factors were identified by the review as contributing to this phenomenon, in particular: 145

147 Unrealistic government assumptions concerning the speed and certainty of students post-arrival English development, in a context where short English courses could deliver guaranteed access to degree and diploma courses via packaged visas; Potentially compromised academic entry and progression standards (in select institutions); Inadequate surveillance and quality control of the burgeoning vocational education sector; and The high level of cultural and linguistic enclosure experienced by many international students located in the Sydney or Melbourne campuses of select regional universities and private vocational training bodies, where students experienced near total academic segregation. These issues were irrelevant to most former international medical and allied health students. The great majority secured elite rather than inferior Australian outcomes, with employment and salary rates at 4 months highly comparable to those achieved by domestic students. (See Table 55.) The main exception was the English language standards on exit of some international nursing student graduates 12. Table 55: Median Annual Salaries ($AUD) for Australian Graduates Working Full-Time in Australia by Select Field, Domestic Compared to Non-Permanent Resident ( ) Median annual salary ($AUD) Number of graduates Discipline Resident status Total Total Australian citizens or Permanent Residents 50,000 54,050 53,000 55,000 57,000 55, Medicine Nursing Dentistry Physiotherapy National total Non-Permanent Residents 48,000 53,300 50,000 55,000 54,000 52, Australian citizens or Permanent Residents 40,000 42,000 44,710 46,000 48,000 43, Non-Permanent Residents 42,000 42,337 45,000 47,000 47,000 45, Australian citizens or Permanent Residents 75,000 70,980 80,000 80,000 84,000 80, Non-Permanent Residents 68,000 78,000 95,000 75,000 75,000 76, Australian citizens or Permanent Residents 43,000 45,000 47,916 48,000 50,000 47, Non-Permanent Residents 43,250 44,000 45,000 47,895 49,000 47, Australian citizens or Permanent Residents 42,000 44,000 46,000 49,000 50,000 45, Non-Permanent Residents 38,000 40,000 40,000 44,000 42,000 40, Source: Analysis of Graduate Destination Survey data (all Australia) by Anna To, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne (2011). Please note cases were excluded where salaries were not given. Location of First Professional Employment Former international students were also well distributed in terms of location. As demonstrated by the Graduate Destination Survey, in the last 2 year period (based on responses for 2009 and 2010) 3,106 former international students were resident and employed in Australia 4 months following course completion. Their locations, in descending order by state/ territory, were: 12 Select institutions which enrol international nursing students at IELTS Band 6 at point of course commencement have no capacity to guarantee these students will have reached the requisite level for registration of IELTS Band 7 or OET B by course completion English ability also affecting scope for transition to GSM migration. 146

148 Melbourne (927) and Other Victoria (83) Sydney (787) and Other NSW (81) Perth (417) and Other Western Australia (19) Brisbane (232) and Other Queensland (128) Adelaide (303) and Other South Australia (21) ACT (52) Hobart (25) and Other Tasmania (15) Darwin (9) and Other Northern Territory (5) Other (2) Interestingly, former international students were less likely to be working in regional sites than domestic graduates, except in the field of medicine (where the rates were 24% compared to 22%). Recent GSM Policy Refinements It is worth noting here the Australian government has taken steps to refine the study-migration pathway to enhance international students employment readiness since 2007: Exemptions from English testing have no longer been automatically allowed, given the impossibility of policing education provider standards 225. IELTS Band 6 has become the threshold GSM competence score across all 4 skills (increased from IELTS 5). Significant bonus points have been introduced for advanced English (IELTS 7 or above), with English becoming a key determinant of points-based selection. Higher points are awarded graduates with advanced qualifications: most notably applicants possessing doctoral degrees, masters or bachelor qualifications. Liberalised access to post-course visas has been introduced, allowing students an additional 18 months to upgrade their skills for GSM selection ( gain skilled work experience;; improve their English language skills;; or undertake a Professional Year related to field of study 226 ). Employer-sponsored and state/ territory nominated applicants have been accorded priority processing an option for example fast-tracking the selection of recent medical graduates securing Australian internship offers, and recent nurse or dental graduates offered public sector and/or regional employment. 7.7 Former International Medical Students in Australia Case Study On this basis international students future retention in Australia is a key policy issue. A recent study explored motivation versus outcomes in relation to medicine 227 (noting that more extensive research is now underway, commissioned by the Medical Deans of Australasia) 228. A survey was conducted in of 619 international medical students in their final 2 years of undergraduate and graduate entry medical courses across eight Australian universities (Melbourne, Monash, Adelaide, Western Australia, Queensland, Newcastle, NSW and Flinders). This was followed by a 2009 survey of 88 international medical graduates of the University of Melbourne (most of whom had responded to the earlier survey). The aims of the study were to assess students preferred internship location, the correlation between intention and actual placements in their first postgraduate year, and the proportion of respondents who hoped to remain in Australia to practice. 147

149 Of the 619 international medical students surveyed in 2006, 358 (58%) responded. Most planned to seek Australian internships and secure permanent resident status, although a third were undecided on this long-term. Nationality was a highly significant variable, with students from Africa and the Middle East (91%), Malaysia (84%) and Singapore (81%) most likely to wish to stay a pattern far less marked for Canadian and US respondents (66%). The majority sought city rather than regional or rural locations (though willing to go to either). The subsequent 2009 survey of the University of Melbourne s 2008 medical graduates showed a high correlation between students mid-course plans and outcomes in their first postgraduate year, with 73% accepting Victorian internships. (See Table 56.) A 2011 survey of the University of Melbourne s 2010 graduating class found these outcomes had been maintained, with identical proportions of international students securing internships, largely in urban locations (most notably the Austin/Northern, Eastern Health, St Vincent s, Western and Melbourne Health). (See Table 57.) Table 56: Victorian Internship Destinations for International Students Graduating from the University of Melbourne MBBS Degree ( ) Hospital/ Health Service Alfred Health Austin/Northern Ballarat Health Barwon Health Bayside Health Bendigo Health Eastern Health Gippsland Goulburn Valley Melbourne Health Mildura Peninsula Health Southern Health St Vincent s Western Health Total Source: Hawthorne, L & Hamilton, J (2010), International Students and Migration: The Missing Dimension in Australian Workforce Planning?, Medical Journal of Australia, Vol.193 Issue 5: 3-6 (6 September), Table prepared by A Langley. 148

150 Table 57: Victorian Internship Destinations for International Students Graduating from the University of Melbourne MBBS Degree (2011 for 2010 Graduates) Hospital / Health Service University of Melbourne International Student Internship Places Albury Wodonga Health - Alfred Health - Austin/Northern 19 Ballarat Health 1 Barwon Health 1 Bendigo Health 1 Eastern Health 7 Gippsland - Goulburn Valley 5 Melbourne Health 6 Mildura - Peninsula Health 6 Southern Health 1 St Vincent s 7 Western Health 7 Total ( ) 61 Source: Based on unpublished data collated by A Langley, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne (April 2011). Australian graduates are an attractive training proposition for hospitals relative to many IMG s. According to a Western Australian key informant, by 2009 Western Australia was catering to a bulge of new graduates, with double the number of internship places required despite limits to clinical supervision. Permanent residents deemed poor in English and clinical skills were certain to lose out (often in the past having been taken on by hospitals as a last resort, and perceived to need more than 12 months clinical supervised placement to secure full registration). In the view of one clinical informant, need for (permanent resident) IMG s in Western Australia will disappear in the next 3 years There won t be the (previous) 50 clinical places. 229 This trend is now well underway, with many international students ranked ahead of IMG s for Australian clinical placements. Motivation to Migrate: Former International Medical Students Current and former international medical students interviewed in recent years describe significant motivation to remain in Australia post-qualification, with the following quotes derived from taped and transcribed interviews 230. Most notably: Chinese and Indian origin students from Malaysia express concern at limited academic and professional prospects back home, reflecting the longstanding bumiputra policy which favours the advancement of native Malays: It s a beautiful place but the opportunity is not equal if I were to buy a piece of land, I would have to pay a higher price. If I were to send my kids to school the exams would be different There is this quota system back home and (around) 70% of medical spots will be given to Malays and then 20% to Chinese and 10% to anyone else 149

151 My friends (in Malaysia) told me I would be crazy to go back because things are looking not quite good in the future in terms of either a Chinese or Indian Students have often strongly adapted to Australia during their course of studies, preferring to remain rather than become professionally and/or personally displaced: The only culture shock I had here was that the professors and doctors are extremely friendly and very enthusiastic I think I am really, really comfortable with the lifestyle here, and also the people are really friendly, and I have all my friends here, so I definitely want to stay After spending my first year here it was almost as though we had taken a breath of fresh air for the first time. Things were so different. We had equal opportunity, and watching Insight you could see people criticising John Howard It was a huge culture shock to me! The quality of Australian internship training is highly regarded: You know my colleagues are all very very supportive and very helpful, and all the senior doctors are very approachable, and they actually enjoy teaching as well We are working shift work and I love that. I think the Emergency Department is really a good place to begin your internship (I)n the ward you are able to see the progress, and you can develop doctor/patient relationships which is fantastic Disappointments? So far I really can t say. I have been having a wonderful time Postgraduate training back home by contrast can seem problematic: Apparently back home if you are not from the right background (you may be sent) to rural areas to do your work very poorly supported and very poorly paid In Singapore interns have a very, very high workload that is one issue why I want to stay here In Malaysia (after qualifying in Australia) they told us we would have to serve the government for a minimum of 3 years, and even after (work) in the public sector They have now told us they will put us in rural areas, and even if (I wanted to specialise) I might be placed in a small rural setting that is not accredited for Psychiatry or O&G or anything. So it would not benefit me or anyone else, as we could not be distributed to our specialities. I think the doctors are overworked and they are not paid penalty rates. I think you would probably be paid twice (or more) here compared to home Securing a 457 visa nomination is viewed as a straightforward process, so long as an internship is secured: The hospital as nominee fills out the application form for us, they put in the applications and we finish the rest of the procedure Australian regional hospitals are deemed friendly and welcoming from previous exposure, despite students attraction to capital cities: I came to (names a regional city) in semester 8 and that rotation was fantastic. We had been attached to a very great surgical team, and the hospital environment is fantastic. Everybody is very friendly, give us a good impression, and that is the main factor why I want to come back to this hospital... Everyone could see me, and the next day I could see them again, and they would introduce themselves and I got to know them. It was easy getting around. I found it really easy to study medicine (on rural rotations) because you can be there at any time and you 150

152 know any ward will say okay, there s a patient who needs close attention, or they might have an interesting symptom and you (are welcome) I don t mind going to regional areas. I did really enjoy my rural rotations (while studying medicine) and I do plan to serve in the country once in a while it s not that I just want to stay in the metro area to work So I was enjoying everything, and I thought a GP would be a good option, in particular a rural GP But some other people have told me to return to the metropolitan area because there is more opportunity to do postgraduate training Former students see excellent future options for postgraduate training in Australia: At the moment I am thinking of choosing Paediatrics or General Medicine. Another reason I want to stay in Melbourne is because the Royal Children s Hospital is a fantastic (place for training) I see (my career) developing and I am really interested in the academic side of medicine. I am planning to do a bit of research if I get into surgery If possible I want to stay here to continue my specialist training. In Singapore they have their own training, but sometimes you have to fly to the US or UK to get a diploma it s not like you are already in the stream. Canadian Medical Students Migration Intentions As noted, Canada has emerged as Australia s third top international medical student source countries in recent years, with 437 enrolments by 2009 (following Malaysia and Singapore), rising rapidly since. (See Table 42.) The extent to which Canadian students will migrate is currently unclear. Very substantial numbers however are interested in doing so, and this seems likely to remain the case. Interviews conducted with hundreds of prospective Canadian medical students in the past 4 years suggest the majority are motivated to study in Australia as a result of: Being near misses in securing medical places in Canada (the motivation to study abroad for 78% of all Canadian students 231 ) The perceived calibre of Australian medical education Attraction to a better climate The prospect of global adventure A desire to replicate their parents migration trajectory (disproportionate numbers of Canadian students being first generation Canadians) Within this context, an interest to explore diasporic and family links with Australia 232 There is immense current Canadian concern at the perceived threat to Australian internship places 13. According to North American agents, this uncertainty is causing a drop in applications to study medicine in Australia, in a context by 2009 where 3,570 Canadian medical students were enrolled overseas (2,000 in the Caribbean, 650 in Ireland, 550 in Australia, and 300 in Poland), in addition to large numbers in the US. Those qualifying abroad have no certainty of residency places should they return to Canada 21% being the Canadian Resident Matching Service published norm 233. While Australian-trained applicants have the highest placement rate (reportedly around 55% 234 ), increased numbers of Canadian graduates are likely to wish to stay. It is worth noting in relation to that Australia-trained physicians also secured the highest candidate pass rates in the Medical Council of Canada 2010 IMG exams (99%) This issue was repeatedly raised to the author in May/June 2011, in individual and group interviews with prospective students conducted across Canada. 151

153 7.8 Attracting and Retaining International Students 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 thus seem less problematic than the OECD migration norm - selection of matureage professionals fully trained by their source countries. Australia s global competitors are currently intensifying their competition for international students as skilled migrants examples including Canada, New Zealand, the USA, Japan and Germany. As demonstrated, former international students constitute an exceptional health workforce resource. Thousands are enrolled in Australian medical and allied health degrees, with numbers increasing. Regardless of source country, former students secure strong employment outcomes in their qualification field. Employment and salary rates at 4 months are near identical to those enjoyed by domestic students, in stark contrast to overseas-trained health professionals admitted through Australia s family and humanitarian categories. They far exceed the achievement at 6 months of General Skilled Migration primary applicants. A key policy issue is the extent to which international students should be prioritized as a future health workforce resource, relative to permanent and temporary resident offshore migrants. A second issue concerns the policy levers which could/ should be used to effect this. As is widely understood, there will be winners and losers in any such process. For example competition for clinical training places is transforming in terms of medicine threatening the displacement of IMG permanent residents at the end of the Australian Medical Council pathway. 152

154 Section 8: The Challenge of Retaining Migrant Health Professionals 8.1 The Emigration of Health Professionals from Australia Scale of Emigration by Age and Birthplace Health workforce migration is contentious, in a context where OECD nations increasingly compete for global workforce supply, attracting international medical and allied health graduates from Asia, Africa, the Caribbean and other OECD members 236. Beyond the challenges 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 to In ,875 health professionals emigrated permanently from Australia, compared to 2,203 in The majority were of prime workforce age. Females dominated - a striking 72% of the total, reflecting the mobility of domestic and international nurses. (See Table 58.) Table 58: Emigration of Health Professionals from Australia, by Gender and Age ( to ) Gender Age group Total No. No. No. No. No. No. Males Less than 25 years years years years years years years years years years Male Total Females Less than 25 years years years years years years years years years years Female Total Total Percentage (Males) 28% 28% 28% 28% 27% 28% Total Percentage (Females) 72% 72% 72% 72% 73% 72% Total departures of Health Professionals Total departures Source: Analysis of Department of Immigration and Citizenship unpublished statistics, provided to Health Workforce Australia (May 2011) The majority of health professionals leaving were Australia-born (48% or 1,371 people), followed by health professionals born in New Zealand (14%), the UK (11%), China (4%) and Hong Kong SAR (3%). Many were returning home. (See Table 59.) 153

155 Table 59: Emigration of Health Professionals from Australia, by Country of Birth ( to ) Rank Country of Birth Total No. No. No. No. No. No. 1 Australia New Zealand United Kingdom Hong Kong (SAR of China) China (excludes SARs and Taiwan) Ireland Malaysia United States of America Philippines Canada South Africa VietNam Taiwan India Fiji Germany Singapore Netherlands Tonga Papua New Guinea Other countries Total(a) (a) Total includes Country of Birth 'Not stated' Source: Analysis of Department of Immigration and Citizenship unpublished statistics, provided to Health Workforce Australia (May 2011) Emigration Trends by Field, Gender and State/Territory Health professionals out-emigration was significant in the following fields: Medicine: 540 permanent departures in (compared to 424 in ) Nursing: 1,274 permanent departures in (compared to 988 in ) Dentistry: 53 permanent departures in (compared to 70 in ) Physiotherapy: 174 permanent departures in (compared to 103 in ) Pharmacy: 123 permanent departures in (compared to 81 in ) Other allied health professions: 711 permanent departures in (compared to 537 in ) Emigration flows were fairly even split in terms of gender by : Medicine: 310 males permanently departing compared to 230 females Nursing: 121 males permanently departing compared to 1,153 females (reflecting the highly feminised nature of nursing) Dentistry: 32 males permanently departing compared to 21 females Physiotherapy: 61 males permanently departing compared to 113 females Pharmacy: 30 males permanently departing compared to 93 females Other allied health professions: 240 males permanently departing compared to 471 females 154

156 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 overseas-born doctors permanently departed, compared to 195 who were Australia-born. Thirty-nine migrant dentists left, compared with 12 born in Australia. Departures were more balanced in other fields for example 607 migrant nurses permanently departing compared to 600 born in Australia. As demonstrated by Table 60, 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. 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 in the 2009 National Health Workforce Taskforce report. 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 care 237. Table 60: Emigration of Australia-Born and Migrant Health Professionals from Australia, by State/ Territory ( to ) State of Previous Residence No. No. No. No. No. No. New South Wales Victoria Queensland South Australia Western Australia Tasmania Northern Territory Australian Capital Territory Total departures of Health Professionals(a) Total departures (a) Includes departures from 'Other Territories' Source: Analysis of Department of Immigration and Citizenship unpublished statistics, provided to Health Workforce Australia (May 2011) 8.2 The Hyper-Mobility of International Medical Graduates Migration Pathways and Motivation Migrants retention in regional sites also represents a critical issue (noting the growing state/ territory sponsorship trends described in Section 1). Modest research however has been commissioned on this subject to date, despite some exploratory medical studies 238. An analysis by Han & Humphreys in 2003, based on 57 interviews with IMG s in regional Victoria, found that: Many rural communities throughout Australia depend on international medical graduates (IMGs) for the provision of primary health care. To date, however, it is not clear how well they integrate into rural communities or how long they intend to stay in practice there. This study reports the results of in-depth interviews undertaken with the aim of identifying which factors facilitate or inhibit their integration into rural communities and consequently affect their intention to stay in rural practice. Based on 155

157 the interview results, four different types of IMGs were identified according to their level of integration into rural communities. They are satellite operators (city-oriented), fence-sitters (affiliated with city fringe areas), the ambivalent (unsure about their future settlement place) and those integrated into rural communities. Recognition of such a typology is useful in assisting to better target support and incentives designed to increase IMG rural retention rates towards those doctors most likely to remain in rural practice on completion of their mandatory period 239. Rural Workforce Agency, Victoria Research on Retention (2003) A more extensive analysis was commissioned by the Rural Workforce Agency, Victoria, based on a mail-out survey of all 245 IMG s then employed in regional general practice in Victoria. (This secured a response rate of 38% or 84 completions, satisfying statistical power requirements 240.) Thirty-one percent of respondents were derived from continental Europe (in particular the former USSR and Poland), 30% from Asia, 13% from Africa (predominantly South Africa), 125 from ESB source countries (most notably the UK), and 12% from the Middle East (primarily Egypt and Iraq). To supplement these surveys, 37 extended interviews were conducted with individual IMG s across 29 Victorian regional sites, with tapes fully transcribed for analysis. International medical graduates responding to the survey had reached Australia through virtually every immigration category, including 32% in the family category, 21% as GSM migrants, 20% via a range of temporary visa categories, and 13% in the humanitarian program. Findings are quoted at some length, given the insight they provide on IMG s regional retention. Please note that there is a dearth of information to date on regional retention related to the allied health professions. Hyper-Mobility At their time of arrival 60% of medical respondents stated they were primary applicants, with 30% non PA s, and the remainder unsure. Their settlement intentions were mixed at point of entry, with 70% planning to stay permanently, 26% uncertain, and 4% envisaging temporary sojourns. By the time of the survey administration however 51% of all respondents had become citizens, with a further 32% reporting permanent resident status, and 16% still on a temporary basis. The most striking finding of the study was the entrenched hyper-mobility of overseas trained doctors then located in Victorian rural/regional general practice. Sixty-six percent of all respondents reported having made 5 major geographical moves prior to their current position (migrating to one or more countries and then additionally within Australia). Thirty percent had made 3 to 4 moves, with 5% reporting an extraordinary 6 to 8. The qualitative interviews graphically illustrated this process, revealing up to 10 geographic relocations undertaken by a single informant. (See Table 61.) When analysed by region of origin, Asian-origin doctors were found to be 5 times more likely to have reached Australia via a third country when compared to the others (all regions combined, OR 4.95 [95%CIs: ]) - a highly significant difference. Such patterns, once established, might not be easily broken, making long-term commitment to a randomly chosen location unlikely. 156

158 Table 61: Relocations Reported by a Random Sample of IMG s in the Interview Research Sample Movement Trajectory East Europe New Zealand Melbourne Central Victoria (regional city) Central Victoria (small town) East Europe European Union Melbourne range of international locations Tasmania (small town) Melbourne Northern Victoria (small town) Middle East Perth Melbourne North-west Victoria (regional city) Central NSW (regional city) South Western Victoria (small town) Middle East Gulf States Melbourne Western Australia East Gippsland (regional city) South Asia South Africa (3 rural and 1 urban location) Queensland (x2 rural locations) North Victoria South Asia UK South East Asia (x 2 countries) North America New Zealand Central Victoria (regional city) Central Victoria (small towns x2) South-east Asia India Melbourne Sydney Central NSW (small town) East Gippsland (small town) East Asia New Zealand Brisbane North-west Victoria Melbourne East Gippsland (small town) East Gippsland (additional small town) Africa Middle East Gulf States Perth North-west Victoria (regional city) North-west Victoria (small town) Africa UK other African countries (x2) South-east Asian countries (x3) Sydney Southeast Asian country Sydney South-west Victoria (small town) Source: L Hawthorne, B Birrell, B & D Young (2003), The Retention of Overseas Trained General Practitioners in Regional Victoria, Rural Workforce Agency Victoria, Melbourne, Table 11, p. 32. The number of years spent working in a second country could be very extensive, with 28% of such informants stated they worked for just one year in country 2, but 63% stating they had worked for 2-7 years before moving on. Stays of 5 years or more did not therefore signal permanent retention. For many IMG s migration to Australia was part of a sequence of carefully strategised moves, designed to transplant families from third to so-called first world countries where they could secure significantly greater career rewards. This pattern was particularly associated with IMG s of Asian origin. As one informant stated: I was born in (South Asia) and when I got married I moved to a major city. When I didn t get the speciality I wanted I went to (Europe) to do my qualification there. From there I came back to (South Asia). It was a bit difficult financially so I felt I would go out to the Gulf States. I worked in one of the hospitals there for 18 months. It was a completely different culture for me. Then we went to New Zealand and we had to search for jobs at that time with no family support there. We were a bit frustrated financially so one of our friends who worked in Southeast Asia said, Why don t you come here? We moved there for a number of years, but my qualification was not recognised. So we debated whether to do some studies or migrate to a different place where we could both get a job. Then we decided on Australia, as we had New Zealand citizenship. I came first. 157

159 Improved lifestyle and opportunities for children were the primary reasons international medical graduates elected to come to Australia (40%), their comments making clear that such motivations were inextricably linked. Additional reasons cited were pre-existing family links (23%), security/safety (21%), career opportunity (12%), and adventure or sea-change, particularly at a critical junction in life (4%). The point to note is that career opportunity was relatively unimportant in determining Australia as a destination choice an issue indicating the extent to which IMG s might let non-career factors determine future practice locations. Choice of State and Current Location In marked contrast to choice of country, career opportunity was the primary reason overseas trained doctors reported they came to the state of Victoria (39%), followed by access to family/friends (38%), the intrinsic attractiveness of Victoria as a state (14%), and RWAV s rural GP recruitment scheme (4%). A high 61% of IMG s stated that job-related reasons had been the critical determinant in coming to their current rural location - suggesting if positions proved disappointing they might have minimal incentive to stay. Importantly a substantial number of doctors stated that they saw this site as their only current medical option (in other words a highly constrained choice). It is important to recall that many such IMG s were indeed captive. Sixty-nine percent of all respondents had achieved only conditional medical registration by the time of the survey. The majority of permanent residents had attempted without success to pass the AMC pre-registration exams, meaning they were eligible to work as general practitioners only in areas of need or comparable sites. Those with full registration were working to reduce the period required for eligibility to bill on Medicare from 10 to 5 years. Visa conditions for temporary resident IMG s were similarly constrained in terms of GP location options. IMG s reported they had secured their first medical registration in a range of states, confirming the willingness of those in Australia to shift to improve their career options. While 27% of all respondents had been placed in their current position immediately on arrival, 22% had been without work for 4-12 months post-migration, 10% for 1-2 years, and 30% for 2 or more years (including some for very extensive periods). Within this interval many had become desperate to secure medical work, after years spent trying to pass AMC exams in relative isolation, convinced that clinical exposure would assist them to do this while they earned. As public sector House Medical Officer positions had become available to IMG s (reportedly from the mid to late 1990s), these were readily taken up. Such employment however could be far from ideal in terms of work/ study/ family combinations. An African doctor recalled his professional transition, following years of unemployment: In the base hospital in the Emergency Department it was very long hours, minimum 10 to 17 each day. And the toughest was the night shift because it runs from 8 to 9 in the morning. Weekends were really very hard, because you are left alone in the Emergency Department and you are responsible for the whole hospital I can say all the Emergency doctors were from overseas. Three from (the Middle East), one from Vietnam or Thailand, two from India or Sri Lanka. I am sure everybody is not happy there. But they cannot complain. For the locally trained doctors, they work a maximum of ten hours. I didn t see any one of them who had more than ten hours. Plus the payment was not done equivalent to the hours you are working, so it is a lot worse. I am sorry to say that it is exploitation. There were no local doctors working overnight unless it is like a locum under very restricted circumstances. No time even for my social life. It was really very hard. My family was living in (a capital city interstate) so it was very hard for both sides. 158

160 Once the opportunity of rural general practice positions emerged, permanent resident doctors swiftly transferred to the Rural Locum Relief Program an option many regarded as infinitely preferable to the rigours of HMO work. Describing his transition, the African doctor quitting the exploitive base hospital position (above) reported Double the money for half the hours! Factors Likely to Impact on Doctors Retention in Rural/ Regional Positions Fifty-two percent of survey respondents reported that they expected to stay in their current location long-term (6-10 years more), compared to 24% who planned to stay for 4-5 years, 8% for 1-12 months more, 5% for 2 more years, and 6% for 3 more years. However the majority of IMG s did not choose to serve long-term once they had less constrained options. Overall, the following factors appeared critical in terms of 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 work. 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 specific periods of time, their aspirations are directly comparable to those determining the practice choices of mainstream Australians. It is important to note that identical trends prevail in relation to this in Canada, the USA, New Zealand, Africa and the Gulf States. Competition for the best sources of international health professionals is set to intensify for Australia in the future, as defined in Section 2. This issue has been addressed in depth by recent OECD and WHO reports, supported by country-specific studies 241. Two short case studies are provided to illustrate these trends, related to major competitors for Australia - New Zealand and Canada. 8.3 Case Study 1 New Zealand Migration and Registration of International Medical Graduates According to a recent OECD analysis, by New Zealand had the highest proportion of foreign born doctors (52%) and foreign-trained doctors (36%) in the OECD; a lower physician density than the OECD norm (2.2 practising per 1,000 population compared to 3.1); and the third highest OECD rate for expatriation of doctors (28.5%) 242. While no specific migration visa has been created to facilitate health workforce migration, medical practitioners enter New Zealand 159

161 through temporary and permanent pathways in response to sustained demand, to offset the high emigration rates of health workers, mainly to other OECD countries. Modest numbers are retained, in a context where international migration constitutes at once an opportunity and a challenge for the management of the human resources for health in New Zealand at a time of ageing patient and practitioner populations: To date, immigration has been a very significant part of the supply of health workers in New Zealand. However, further increase in the number of overseas-trained health professionals might place New Zealand in a delicate position, as it could become too dependent on immigration in a context where many other OECD countries are also looking to recruit foreign doctors and nurses 243. Despite what the OECD terms repeated calls for self-sufficiency in recent official reports, New Zealand trains proportionally fewer medical graduates than other OECD countries, and to date attracts few foreign medical students. According to recent Department of Labour/ Statistics New Zealand data, 7,102 work permits were issued to IMG s by New Zealand from , along with 1,612 SMC principal applicant permits 244. The UK was by far the largest source, followed by the US, India and South Africa. By June 2009, as reported in the Medical Council of New Zealand Annual Report, New Zealand included 12,493 practising doctors 245, with 323 new domestic graduates also registered that year. This figure was dwarfed however by the number of international medical graduates registered (1,141). As in Australia, large numbers of these IMG s would practise under conditional forms of registration. All would be required to hold annual practising certificates. The top 10 source countries at this time were England (2,403 arrivals, 1,502 with practicing certificates), followed by South Africa (1,105 arrivals, 796 with practicing certificates), Scotland, Australia, India, USA, Sri Lanka, Ireland, Germany, and Iraq. By ,518 doctors held provisional general registration in New Zealand, out of a total 17,713 doctors on the medical register. IMG s typically gained registration by being a graduate of a competent authority accredited medical school (453 IMG s that year), having worked in a comparable health system (288 IMG s), or having passed the NZREX Clinical exam (44 IMG s). Alternative pathways included non-approved postgraduate qualifications in specialty fields, and special purpose categories catering for example to visiting locums and specialists (231 IMG s). Migrant doctors eligible for the fast-track competent authority pathway in 2009 had trained in England (280), Scotland (73), Ireland (72) and Wales (28). Those deemed to have qualified in a comparable health system (288 IMG s) were sourced from 22 listed countries in rank order that year derived from Canada, India, the Netherlands, Sweden, Belgium, Nigeria, South Africa, Italy, Singapore, Denmark, Austria, Pakistan, Finland, Hungary, Myanmar, Brazil, Poland, Russia, Spain, Sri Lanka, Barbados, the Dominican Republic, Iceland, Montserrat and Nepal. To manage such eclectic flows, New Zealand is establishing simpler supervisory procedures while providing more orientation information; requiring newly registered doctors to work under supervision; ensuring greater accountability to stakeholders; and moving to more sophisticated range of assessment practices. 246 Retention Challenges Despite this investment in training, migrant doctor retention represents a major challenge. In 2008 the New Zealand Medical Workforce survey defined the following outcomes for IMG s, in a year where they constituted 39% of New Zealand s practicing doctors, compared to 36% in Employment was highly segmented, with IMG s disproportionately employed in the previous 3 years as medical officers (constituting 60% of the MO workforce), registrars (36%), and house officers (21%). IMG s also represented more than 50% of the workforce in the following specialties: accident and medical practice, palliative medicine, psychiatry, radiation oncology, 160

162 rehabilitation medicine and neurosurgery 247. This reliance is on IMG s is worsening at the present time. A New Zealand paper released in August 2010 noted that 19 of the 26 medical specialties and sub-specialties require workforce increases of more than 20% to meet the recommended specialist-to-population ratios. Eight require increases of more than 50%, and four require increases of (over) 100% 248. Within this context IMGs presence remains essential to offset the departure of New Zealand doctors: 83% of whom remain in New Zealand two years postgraduation, declining to two-thirds by 8-12 years. International medical graduate retention however is also problematic. According to the Medical Council of New Zealand by 2008 just half all IMG s were retained for one year (compared to 36% in 2003, when large numbers were crossing the Tasman to Australia 249 ). Retention dropped to 31% within 3 years of initial registration - a trend now consistent for the past 8 years. Just a quarter of IMG s remain in New Zealand 8 years following their first registration. The highest retention rate is of Asian doctors (50% resident 7 years after initial registration). Less than 50% of South African IMG s however remain in New Zealand more than 5 years, less than 30% of UK doctors more than 2 years (dropping to 20% after 6 years), and less than 30% of US or Canadian doctors more than 1 year (the lowest rate, in a context where fewer than 10% remain in New Zealand after 4 years). Retaining young migrant doctors is particularly hard - just 20% of those aged years resident for more than 2 years, with mid-career migrants the most stable recruitment option 250. These retention rates inevitably have impact on the viability of IMG training programs. According to the Medical Council of New Zealand 251, $NZ11.8 million was allocated to bridge 300 migrant doctors into full registration in a recent 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 (eg from refugee doctors), in the light of New Zealand s modest overall IMG outcomes. Migration and Registration of International Nursing Graduates The patterns defined above are largely replicated in relation to nurses. As noted by the OECD ( Health Workforce and International Migration: Can New Zealand Compete? ) by New Zealand had among the highest proportion of foreign born (29%) and foreign-trained nurses (24%) in the OECD, plus the second highest OECD expatriation rate for nurses (23%) 252. By the time of the 2006 Census 23% of New Zealand s nurses were overseas-born, with a Nursing Council of New Zealand report estimating they constituted 27% of registered nurses in According to the latest Department of Labour/ Statistics New Zealand data, 6,192 work permits were issued to IEN s by New Zealand from , along with 4,382 Skilled Migrant Category residence permits 253. In total 18,132 work permits were provided to migrant medical and health workers those 4 years, with 8,496 SMC principal applicant permits. Nurses constituted the largest group (10,574) followed by doctors (8,714). The UK was again the major source, followed by the Philippines (rapidly rising), India and South Africa. Despite these trends nurse migration barely rated a mention in the New Zealand Health Workforce report of 2002 its focus being domestic training/ retention, including the greater participation of Maori and Pacific peoples 254. A 2009 assessment by Walker describes nurse migration in greater detail 255. By the time of the 2001 Census, major birth countries for employed 161

163 nurses in New Zealand were the UK (3291), Australia (615), South Africa (432), Philippines (426), Fiji (405), Netherlands (309), Samoa (285), Ireland (186), China (177), Tonga (171), Malaysia (138), Canada (135), India (114), Germany (111), USA (105). In all 7,498 foreign born nurses were working in New Zealand at this time, compared to 25,425 who were New Zealand born. As with Australia, migrant nurses entered New Zealand through multiple pathways - Department of Labour data, for instance, showing 1,227 caregiver temporary work applications for alone compared to just 50 in The Nursing Council of New Zealand (the key registration body) reported 1,465 overseas registrations in 2007 (59% of all new registrations). According to a 2009 assessment of New Zealand s national regulated nursing workforce, the primary places of qualification for migrant nurses working in New Zealand by this time were the UK (3,939), the Philippines (1,068), Australia (676), South Africa (652), and India (589), with Filipino and Indian arrivals increasing rapidly. (Since 2001 Filipino nurses had tripled in number, while Indian arrivals had grown eight fold.) Retention, as with migrant doctors, has been a major challenge - a survey by the New Zealand Nurses Organization demonstrating 27.5% of IEN s to be unsure of their future plans, while many were considering a return to their country of origin 256. The study by Walker affirmed multiple migration pathways to be the norm nurses arriving in rank order as visitors, students, work permit holders, and following this as SMC migrants. Many post-arrival incurred substantial costs enrolling in Competency Assessment Programmes to secure registration, and/or in English courses prior to taking IELTS or other exams. Prior to 2004 it had been possible to demonstrate competence by hospital employment, a pathway since tightened up. As in Australia, English testing was IEN s biggest hurdle to registration, with just 41% passing on their first attempt. (IELTS 7 was required, with this requirement from January 2009 extended to nurses from English speaking background and Pacific countries.) A second major barrier was accreditation of Filipino nursing schools, given their number had risen tenfold in the past 5 years, with many Filipino qualifications deemed inadequate for New Zealand practice. Thirdly, large numbers of migrant nurses (as in Australia) are at risk of disrupted careers and occupational segregation in the geriatric care sector - many never securing registered nurse status. These migration trends and outcomes are highly relevant to Australia, in a context where New Zealand s reliance on migrant health professionals is acute, and certain to intensify. 8.4 Case Study 2 Canada Scale and Type of Skilled Migration Canada represents a major global competitor to New Zealand and Australia in the attraction and retention of skilled migrants 257. In 2009 Canada selected 252,179 migrants across permanent resident categories (compared to a total of 227,455 in 2000). Skilled category migrants constituted 61% of flows at this time (near identical to New Zealand and Australian levels), compared to 26% in the family category, and 9% who were refugees. Major source regions were the Asia-Pacific (48%), Africa/Middle East (22%), Europe and the UK (20%), South/Central America (8%) and the US (2%), with the primary birthplaces China (29,049), the Philippines (27,277), India (26,122), the US (9,723) and the UK (9,566). Immigrants education levels were also disproportionately high. Forty-four percent of total arrivals aged 15 years or more and intending to work were degree qualified (30% at the Bachelor level and 14% at Masters or PhD level). In line with Australia, their occupations were largely 162

164 professional (51%), followed by skilled & technical fields (26%), managerial (14%) and intermediate & clerical positions (5%). As with Australia and New Zealand, Canada s intake of temporary foreign workers has expanded in the past decade. In ,330 temporary residents were admitted (compared to 305,656 in 2000). That year 178,478 foreign workers entered (compared to 116,540 in 2000). International students were a major group, many with work rights (85,140 in 2009, rising from 69,092 in 2000). Substantial numbers of live-in caregivers also entered Canada on a temporary basis 9,816 in 2009 compared to 2,684 in Canada s top 10 source countries for temporary worker entry at this time were the US (17%), Mexico (10% largely agricultural workers), France (9%), the Philippines (8%, primarily live-in caregivers), the UK and Australia (6% each). As with Australia, decided employer preference was evident for migrants from English (or French) speaking and technologically advanced source countries. Medical and Nursing Workforce Migration By the time of the 2006 Census 35% of Canadian residents holding medical qualifications were overseas-born, compared to 45% in Australia (including many who had migrated as children, with large numbers also of recent arrivals who were not currently in the labour force). As demonstrated by a contrastive study commissioned by the Canadian government, by 2001 medical migrants were disadvantaged in Canada relative to Australia. Just 19% of Indian doctors were employed compared to 66% in Australia, 31% from Hong Kong/ Malaysia/ Singapore (compared to 59%), and 8% from Eastern Europe (compared to 24%) 258. Identical medical elites however thrived in each country (for example 81% of South African doctors employed in medicine in their first 5 years), while doctors qualified in China suffered severe skills discounting in both (just 4-5% securing work in medicine differences in language and training systems constituting major barriers). Nurses migrating to Australia did similarly well by a process greatly facilitated by the provision of free government-supported credential recognition bridging programs 259. The contrast with outcomes for internationally educated nurses in Canada was stark, in a context where 6,358 degree-qualified nurses had migrated the previous 5 years, but growth in professional degreequalified positions was minimal (-1%). Labour market barriers in Canada were severe, exacerbated by the selection of 62% of nurses in non-economic categories. Just 22% of recently-arrived Indian nurses found work in their field by 2001 (compared to 66% in Australia), 22% of Filipino nurses (compared to 35%), and 32% from North West Europe (compared to 45%). Large numbers of nurse arrivals from China remained unemployed (28%) or categorised as not in the labour force (25%). These outcomes were serious, in the context of the scale of nurse arrivals to Canada from such countries in recent years (the Philippines dominating with 2,160 nurses). As demonstrated by Table 62, health workforce migration to Canada has been very substantial in recent years. In the two years from 2007 to 2008, an additional 25,000 health professionals were accepted (as in Australia primarily on a temporary resident basis). 3,125 temporary physicians were allocated visas, compared to 2,581 selected on a permanent basis. Registered nurse migration was slight compared to Australia s scale, but live-in caregiver arrivals were vast (a two-step migration pathway allowing nurses and related workers to transit from temporary to PR status within 3 years). Pharmacy migration was also significant primarily through PR pathways. 163

165 Table 62: The Scale of Health Workforce Migration to Canada 2007 and Skilled Category Permanent and Temporary Residents by Field Canada 2007 Arrivals 2008 Arrivals Physicians: Temporary 1,498 1,627 Permanent 1,137 1,444 Nurses: Temporary 576 1,108 Permanent Nurse Assistants/ Live-in Caregivers: Temporary 13,746 12,864 Permanent 2,841 4,909 Pharmacists Temporary Permanent Dentists: Temporary Permanent Dental Technicians: Temporary Permanent Source: Table prepared by L Hawthorne based on unpublished arrivals data purchased from Citizenship and Immigration Canada (August 2009) By % of physicians in rural and remote Canada were IMG s, compared to 23% of physicians in urban areas. As in Australia, a range of provinces had an extreme level of reliance, including over 50% in Saskatchewan and 405 in Newfoundland. As in Australia, a number of provinces control the issue of billing numbers in under-served areas as a means of directly physicians to other areas of the province. Provisional licences are also provided to temporary resident IMG s by a range of provinces, who are tied by the terms of visa issue to specific locations 260. Competition for the best workers is set to accelerate, in a context where the Canadian government estimates 100% of net workforce growth will occur through global migration within 10 years (reflecting a fertility rate of 1.5). To improve labour market integration outcomes, the federal government has embarked on a foreign credential recognition initiative program, with Health Canada currently investing $C75 million in bridging programs to support the skills recognition of displaced medical and nursing professionals 261. Recent Study-Migration Developments The process of two-step migration is also well under way in Canada. In ,837 temporary migrants converted to permanent resident status (compared to 46,718 in 2000). Forty-four percent did so as foreign workers, while 13% did so through the study migration pathway. Like Australia and New Zealand Canada is now cultivating international students as a major future resource. In December ,138 international students were resident (all fields), including 85,140 who had arrived that year. China (16,375), the Republic of Korea (11,048), India (5,718), France 164

166 (5,320) and Saudi Arabia (5,293) were the major sources, followed by the US, Japan, Mexico, Germany and Brazil. Their enrolment level (as in Australia) was fairly high most notably in the university sector (42%). The Canadian Experience Class (introduced September 2008) is small to date (1,775 PA s in 2009 plus 770 dependants), but planned to facilitate two-step migration from former students and temporary foreign workers. Key current sources are the Asia-Pacific (48%), Africa/Middle East (22%), Europe/the UK (20%), South/Central America (8%), and the US (2%). 262 There will be intensifying competition with Australia for the best source of health professionals. 8.5 Conclusion The level of competition for migrant health professionals will intensify in the future. The OECD and the World Health Organisation have combined to undertake major research on this issue in the past 5 years. According to The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD countries face a challenge in responding to the demand for health workers over the next 20 years. This challenge arises in a world which is already characterised by significant international migration of health workers, both across OECD countries and between some developing countries and the OECD area. Whether these migration floiws increase or decrease over the next 20 years is likely to depend on what combination of human-resource management policies and migration policies is adopted by OECD countries. Raising domestic training rates in OECD countries could contribute to filling the gap and would reduce the pull factors on migration. But, the duration of medical training will limit the potential impact of increasing training in the short run. Migration may continue to play a role, at least in some OECD countries, in managing temporary disequilibria or addressing regional imbalances. However, other domestic human resource policies can also contribute to meeting the increasing demand for health workers...in this context, good practices need to be identified and their transferability evaluated 263. Key strategies proposed by the OECD/ WHO include improving work terms, conditions and (in some fields) remuneration; enhancing retention; facilitating the integration of migrants qualified overseas through best practice initiatives, for example related to foreign credential recognition; developing a more efficient skill mix; and improving worker productivity. In terms of retaining foreign-born health professionals, the report notes: While there is no reason why foreign-trained health workers should behave any differently from domestic trained health workers, in practice they often face specific difficulties that might contribute to recruitment and retention problems In the United Kingdom, for example, foreign-trained nurses encounter language problems, and are confronted with differences in clinical and technical skills, and may face open racism in the workplace Many may choose to change jobs or re-migrate.most countries do not have specific retention policies for foreign health workers, even when the latter represent a large share of the health workforce. Policies aiming at matching skills, improving language knowledge and helping migrants in their new social and cultural environment could thus be very beneficial 264. While a recent Australian report cautions against over-supply, Australia s reliance on migrant health professionals will persist in the coming decade

167 Section 9: Policy Issues and Research Priorities 9.1 Key Policy Issues As stated at the start of this study, 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, 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. As noted, vast numbers of Australian medical and allied health professionals are first generation migrants, admitted as children. These citizens are disproportionately represented in medicine and dentistry a notable success of Australia s post-war mass immigration program, including migrants who first arrived in humanitarian categories (for example from Vietnam). By the mid 1990s, for example, 40% of domestic students in Australian medical courses were overseas-born. A striking 24% were from Asia (six times the Asia-born proportion in the overall population, compared to just 7% derived in total from Europe, the UK/Ireland, and the former USSR/Baltic States). While representing a key component of the Australian health workforce, these health professionals face no labour market barriers. They were not therefore the focus of the current study. Emphasis was placed rather on overseas-qualified arrivals, and former international students eligible to seek work in Australia. The Australian Health Ministers have set a goal for domestic health workforce self-sufficiency by Within this context the policy imperative is to recruit migrant professionals able to contribute effectively in the next 13 years. Key policy findings from the study include the following: 1. Temporary labour migration: Within the recent decade, Australia has placed primary reliance on 457 visa temporary professionals to boost health workforce supply - the route for 34,870 migrants from to , with visa issue linked to work location for up to 4 years. The top 10 recent source countries for temporary health professionals to Australia have been the UK/Ireland (10,910), India (6,420), the Philippines (1,850), South Africa (1,770), Malaysia (1,560), China (1,380), Zimbabwe (1,180), Canada (950), the USA (830) and Sri Lanka (830). 2. Permanent skilled migration: Australia s second major health migration resource has been the General Skilled Migration program - the path taken by 15,940 health professionals from to The major birthplaces for these permanent skilled migrants have been the UK/Ireland (5,370), India (1,610), Malaysia (1,470), China (1,030), South Africa (580), the Philippines (570), the Republic of Korea (540), Singapore (470), Hong Kong SAR (470), and Egypt (430). 14 Please note an additional year of data were available for GSM category migrants. 166

168 3. Additional entry pathways: Large numbers of additional migrant health professionals have arrived unfiltered in advance for human capital attributes as GSM dependents, or through the family and humanitarian categories (many of these migrants certain to seek work). From , according to the Census, 17,721 health professionals in all were admitted to Australia: most notably 9,228 nurses/midwives, 3,200 medical practitioners, 759 pharmacists, 505 dentists and 490 physiotherapists. 4. Trans-Tasman flows: New Zealand is a fourth key contributor to Australian health workforce supply, in the context of mutual recognition of qualifications and free Trans-Tasman movement. In ,247 New Zealand nurses, 240 doctors, 44 dentists and 368 other allied health professionals reached Australia. By ,904 New Zealand nurses/ midwives were resident overall, along with 1,161 medical practitioners, 199 dentists, and 1,892 other allied health professionals (9,155 health professionals across all vintages of arrival). 5. Employer preference: As demonstrated by the evidence, Australian employers have a marked preference for health professionals from the major English speaking background countries, with 15,640 sponsored through the 457 visa program from to (44% of the category total). Comparable proportions of ESB health professionals were selected by DIAC through the General Skilled Migration program (6,900 or 43%) - far higher than the ESB skilled migration norm (17%). Commonwealth source countries are also highly regarded by employers. 6. Employment outcomes for skilled migrants: New Zealand trained health professionals are immediately acceptable to Australian employers. As demonstrated by the data analysis, the General Skilled Migration and 457 visa categories are also generally effective selection tools. Within the recent period, consistently superior labour market integration rates, wages and hours worked have been secured by skilled compared to other category health-qualified migrants. GSM migrants face few Australian labour market barriers compared to family and humanitarian arrivals, for whom elongated and less remunerated pathways are the norm. By definition virtually all 457 visa sponsored migrants are also employed (99% rates at 6 months being typical). 7. English language requirements: A large proportion of migrant health professionals face significant pre-registration barriers. As demonstrated by the Occupational English Test case study, English assessment has an extraordinary impact (even for South African and Indian candidates), which has intensified in recent years. This follows Australia s introduction of the requirement for applicants to pass all four language sub-tests at a single sitting, resulting in overall pass rates dropping from an average of 37% in 2005 to 34% in 2010, with devastating results in select fields. (For example just 43% of 2010 medical candidates passing compared to 53% in 2005.) 8. Factors affecting English testing outcomes: Within this process, migrant health professionals are differentially affected by the location of tests as well as qualification field. Onshore applicants (except for nurses) are highly advantaged compared to offshore candidates, while dental and medical candidates are best placed to pass. Select country of origin groups are very seriously disadvantaged (for example Japanese, Saudi, Egyptian and Filipino candidates). 167

169 9. Access to vocational registration: Beyond English language testing, migrant health professionals have highly variable access to vocational registration (with ESB and Commonwealth candidates best placed to quickly secure this). A wealth of AMC information could be sourced in relation to medical applications, allowing analysis of outcomes by age, gender and place of training, and for specialist as well as generalist qualifications. By contrast minimal data could be sourced on migrants application rates/ outcomes for nursing and other allied health fields. This is an important policy issue to address given the longstanding dominance of nurse migration, and recent growth in allied health flows (for example dental migration doubling from 2001 to 2006). The dearth of information on registration outcomes constitutes a serious impediment to workforce planning. 10. Pathways to registration: For many migrant health professionals access to bridging course training is critically important, in particular for those admitted as dependents and through family or humanitarian categories. Bridging programs however are typically under-resourced, under-researched and provided on an ad hoc basis NESB migrants pathway to full registration often taking years. Few bridging options exist in allied health fields beyond nursing. Additional research is warranted on this issue, including the relative merits of for-credit (eg university provided) and not-for-credit courses. Bridging courses are critical to assure safety to practice, to avoid the risk of two-tier health service provision (most notably in medicine), and for social justice as well as efficiency reasons. According to one regional informant interviewed in relation to medicine: We know of the IMG cohorts who are out there now. There are 52 who do not have Fellowship (status). They re obviously a big concern with the change in registration, and the legislation around having to have a vocational qualification. They re all on a time bomb. And probably around half of them are getting no education or training support. 11. Innovative pathways: In terms of medicine, the value of innovative entry to practice pathways was demonstrated in relation to the Competent Authority model (currently being extended to additional fields, eg physiotherapy). Reforms such as this can give Australia a vital competitive edge. They can also accelerate supply - exemplified by the massive recent growth in arrivals from UK/Ireland qualified doctors (surging to around 3,000 in , compared to a trickle per year previously). 12. International students as a workforce resource: Within this complex policy environment, international students emerge as an impressive health workforce resource. Sustained enrolment growth and source country diversification have occurred in the past 10 years. Numbers have risen, for example from 839 basic nursing enrolments in 2000 to 6,124 in 2009; 1,117 entry to practice medicine enrolments in 2000 to 2,772 in 2009; 173 physiotherapy enrolments in 2000 to 365 in 2009; and 124 dental enrolments in 2000 to 367 in Students characteristics: In rank order Singapore, China, Malaysia, India, Republic of Korea, Canada, Hong Kong SAR, Japan, Indonesia and the USA are Australia s top 10 current undergraduate, graduate-entry and postgraduate student sources (across major fields). By definition, former international students are young, acculturated, and trained to Australian norms. They have full credential recognition, advanced English language ability, and have self-funded to meet Australian professional requirements. They are substantially younger than offshore migrants, 168

170 and likely to have long and productive working lives. Since 1999 DIAC s General Skilled Migration program has facilitated former students retention through two-step migration. Students in turn have demonstrated their eagerness to stay - in recent years constituting from 35-42% of permanent GSM skilled migrants. 14. International students employment outcomes: As demonstrated by analysis of the Graduate Destination Survey for 2006 to 2010, former international students in Australia by four months achieve exceptional employment and salary rates relative to all international students (across every qualification field). In addition, their outcomes far exceed those of health-qualified migrants admitted under the GSM, family and humanitarian categories. For example 98.99% of available international medical students were employed full-time in medicine in 2010 compared 99.7% of domestic graduates; 93.8% of former international dental students (compared with 93.6%); 69.6% of international nursing students (compared to 93.4%), with a further 20.8% working in nursing part-time; and 69.2% of international physiotherapy students (compared to 91.3%), with a further 19.2% working in physiotherapy parttime. Former international students salaries by field were also near identical to those of domestic graduates. 15. Demand for clinical training places: It should be noted that Canada, New Zealand, the US and the UK (among other countries such as Japan) are increasing their efforts to attract and retain international students as a workforce resource 266. In terms of medicine however, it is vital for students to secure Australian internship places - a mandatory requirement to be eligible for skilled migration, noting 66-70% wish to stay. Within this context, health workforce planners must address the growing competition between students and migrants to secure clinical training places a threat to AMC pathway doctors, following years of study, who risk end-point displacement. This policy issue is of growing concern. If unresolved it may curb international medical student migration. 16. Emigration of health professionals: While Australia has clear capacity to attract migrant health professionals, it is essential to note high emigration rates persist - most notably of the Australia-born (48%) followed by health professionals born in New Zealand (14%), the UK (11%), Hong Kong SAR (3%), China (4%), Ireland, Malaysia, the USA, Philippines, Canada and South Africa (1% each). There is limited research 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. 17. Regional relocation: 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 undermining stable distribution and workforce supply. For this reason empirically sound strategies to maximize regional retention are essential. 18. Modelling needs: Within this context there is a perceived need for basic modelling on health workforce supply to inform future planning. According to one key informant: 169

171 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 a need to feed data related to different cohorts of migrant health professionals into this modelling process, including estimates of early productivity, likely registration status, hours worked and length of retention. 19. Impact of new governance strategies: Following the major recent COAG initiatives, there is also 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 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. 9.2 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 effect of this requirement on registration and 170

172 employment to date (for select fields such as medicine, and for select country of origin groups). 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). 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. 171

173 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. 1 Quoted from Hawthorne, L (2012 forthcoming), Doctors and Migration, in Encyclopedia of Global Human Migration, Editors Immanuel Ness, Marlou Schrover, Alex Julca, Peter Bellwood, Hyekyung Lee, Donna Gabaccia Saër Maty Bâ, Aristide Zolberg, Dirk Hoerder, Steven Castles, Greta Gilbertson, Manolo Abella, Wiley-Blackwell, USA. For key references see for example World Health Organisation (2006), Working Together for Health The World Health Report 2006, WHO, Geneva; Zurn, P & Dumont, J-C (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD Health Policy Studies, Paris. 2 Birrell, B, Hawthorne, L & Rapson, V (2003), The Outlook for Surgical Services in Australasia, Royal Australasian College of Surgeons, Melbourne. 3 Department of Health (2005), Data defining numbers of doctors (specialists and generalists) by country of qualification, 2005, National health Service, England, accessed February Medical Council of New Zealand (2009), Medical Council of New Zealand Annual Report 2009, Medical Council of New Zealand, Wellington, pp. 2, Mullan, F (2005). The Metrics of the Physician Brain Drain, New England Journal of Medicine, Vol 353 Issue 17, October 27; Arnold, P (2011), A Unique Migration South African Doctors Fleeing to Australia, CreateSpace, USA;; Ogilvie, L et al (2007), The Exodus of Health Professionals from Sub-Saharan Africa: Balancing Human Rights and Societal Needs in th Twenty-First Century, Nursing Enquiry, Vol 14 Number 2. 6 Mick, S, Lee S, & Wodchis, W (2000), Variations in Geographical Distribution of Foreign and Domestically-Trained Physicians in the United States, Social Science Medicine, Jan, 50 (2): Hawthorne, L, Hawthorne, G & Crotty, B (2007), The Registration and Training Status of Overseas Trained Doctors in Australia, Department of Health and Ageing, Commonwealth of Australia, Canberra, AD007E Englmann, B & Muller, M (2007), Brain Waste Die Anerkennung von auslandischen Qualifikationen in Deutschland, Tur an Tur Integrationsprojekts ggmbh, TP Global Competences, Germany; Herfs, P (2011), International Medical Graduates in the Netherlands a Future of Medical Doctors or Cleaners?, Verlag Dr. Muller GmbH & Co, Deutschland. 9 Mullan, F (2005). The Metrics of the Physician Brain Drain, New England Journal of Medicine, Vol 353 Issue 17, October 27, p. 1812; Zun, P & Dumont, J-P (2008), Health Workforce Migration Can New Zealand Compete?, OECD Health Working Papers, OECD, Paris. 10 Hawthorne, L (2010), How Valuable is Two-Step Migration? Labour Market Outcomes for International Student Migrants to Australia, Special Edition, Asia-Pacific Migration Journal, Vol 19 No 1: 5-36; Hawthorne, L (2010), Demography, Migration and Demand for International Students, Chapter Five in Globalization and Tertiary Education in the Asia-Pacific The Changing Nature of a Dynamic Market, ed C Findlay and W Tierney, World Scientific Press, Singapore, pp Organisation for Economic Co-Operation and Development (2007), International Migration Outlook, SOPEMI Annual Report 2007, OECD, Paris, pp

174 12 Rural Workforce Agency, Victoria (2010), RWAV 2010 Policy and Outreach Services, Rural Workforce Agency, Victoria, Melbourne, accessed June 2011; Health Workforce Queensland (2010), Medical Practice in Rural and Remote Queensland: Queensland Minimum Data Set Report, 30 December, Brisbane;; Rural Health West (2010), Minimum Data Set Report and Workforce Analysis Update, November, Rural Health West, Perth;; Department of Health Western Australia (2007), Engaging Rural Doctors Final Report 2007, Department of Health, Government of Western Australia, Perth. 12 Rural Health West (2010), Minimum Data Set Report and Workforce Analysis Update, November, Rural Health West, Perth. 13 Hawthorne, L (2001), The Globalisation of the Nursing Workforce: Barriers Confronting Overseas-Qualified Nurses in Australia, Nursing Inquiry, Vol 8 (4): , Blackwell Science. 14 Hawthorne, L (2011), Competing for Skills: Migration Policies and Trends in New Zealand and Australia, Department of Labour, Government of New Zealand, Wellington. This was based on statistical data provided to the author by the Department of Immigration and Citizenship, Canberra. 15. Department of Immigration and Citizenship, Settler Arrivals (Canberra: Department of Immigration and Citizenship, 2010): 3; for a detailed analysis see Mark Cully, The Contribution of Migrants to Regional Australia (Canberra: Department of Immigration and Citizenship, 2011). 16 Bob Birrell, Lesleyanne Hawthorne and Sue Richardson (2006), Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra, Chapters 1 and Department of Immigration and Citizenship (2011), Migration Program, Department of Immigration and Citizenship website accessed 18 June 2011, Canberra. 18 See for example Strasser, R, Hays, R, Kamien M & Carson, D (2000), Is Australian General Practice Changing? Findings from the National Rural General Practice Study, Australian Journal of Rural Health, vol. 8, no 4;; Wilkinson, D (2001), Selected Demographic, Social and Work Characteristics of the Australian General Medical Practitioner Workforce: Comparison of Capital Cities with Regional Areas, Australian Journal of Rural Health, vol. 9, no. 1; Humphreys, J, Jones, J, Hugo, G, Bamford, E and Taylor, D (2001), A Critical Review of Rural Medical Workforce Retention in Australia, Australian Health Review, vol. 24. no. 4; Simmons, D, Bolitho, L, Phelps, G, Ziffer, R & Disher, G (2002), Dispelling the Myths About Rural Consultant Physician Practitioners: Victorian Physicians Survey, Medical Journal of Australia, vol. 176, no. 10;; Humphreys, J, Jones, M, Jones, J & Mara, P (2002), Workforce Retention in Rural and Remote Australia: Determining the Factors that Influence Length of Practice, Medical Journal of Australia, vol. 176, no. 10; Wilkinson, D, Symon, B, Newbury, J & Marley, J (2001), Positive Impact of Rural Academic Family Practices on Rural Recruitment and Retention in South Australia, Australian Journal of Rural Health, vol. 9, no Government of Australia (2008), Skilling Australia for the Future Discussion Paper 2008, Canberra; Rudd, K, Swan, W, Smith, S & Wong, P (2007), Skilling Australia for the future Election 2007 Policy Document, Australia Labor Party, Canberra. 20 Medical Deans of Australasia (2011), HWA Taps into Data to Plan Australia s Future, Outcomes, Issue 5, July, p Australian Institute of Health and Welfare (2011), Medical Labour Force 2009, see Tables 5, 9, B1, and A2, Australian Institute of Health and Welfare, and p. 9 of 14 for Explanatory Notes of the Medical Workforce. 22 Joyce, C et al (2007), Riding the Wave: Current and Emerging Trends in Graduates from Australian University Medical Schools, Medical Journal of Australia, Vol 186 (6) ; see also Joyce, C, McNeil, J & Stoelwinder, J U (2006), More Doctors, But Not Enough: Australian Medical Workforce Supply , Medical Journal of Australia, Vol 184 (8). 173

175 23 Since 1998 L Hawthorne has secured annual specified datasets from DEEWR (formerly DEST) carefully coded to capture all school leaver and graduate entry students enrolled in Australian entry to practice medical degrees, as well as allied health courses. These data are reported in Section 7 of this report (Tables 39 and 40). A range of lower estimates are in circulation, which should be contested. For example a recent dataset circulated by the Medical Deans of Australasia appeared to contain a serious underestimate of the number of Canadian students enrolled, at a time when 103 commenced in Semester at the University of Queensland alone, with strong enrolments also in a wide range of other graduate entry courses. 24 For a detailed estimate please see Productivity Commission (2005), Australia s Health Workforce: Productivity Commission Position Paper, Commonwealth of Australia; Australian Institute of Health and Welfare (2004a), Medical Labour Force, Australian Institute of Health and Welfare, Canberra; Australian Institute of Health and Welfare (2004b), Nursing and Midwifery Labour Force, Australian Institute of Health and Welfare, Canberra; Australian Institute of Health and Welfare (2010), Medical Labour Force 2008, Australian Institute of Health and Welfare, Canberra. 25 Australian Institute of Health and Welfare (2010), Australia s Health 2008, Australian Institute of Health and Welfare, Canberra, p Department of Immigration and Multicultural Affairs (1999), Review of the Independent and Skilled-Australian Linked Categories, DIMA, Canberra, p Department of Immigration and Multicultural Affairs (2005), Sponsoring a Temporary Overseas Employee to Australia, Booklet No. 11, November, p House Standing Committee on Health and Ageing (2011), House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors, see all Submissions plus the Public Hearings and final Report, accessed 24 August House Standing Committee on Health and Ageing (2011), House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors, see all Submissions plus the Public Hearings and final Report, accessed 24 August Access Economics Pty Ltd, (2009), The Australian Education Sector and the Economic Contribution of International Students, Australian Council for Private Education and Training, Melbourne. 31 Vertovec, S (2002), Transnational Networks and Skilled Labour Migration, COMPAS Paper, Oxford p Hawthorne, L & Hamilton, J (2010), International Medical Students and Migration: The Missing Dimension in Australian Workforce Planning, Medical Journal of Australia, Vol. 193, No. 5, 6 September. 33 International student enrolment data for these and subsequent sections are derived from analysis by L Hawthorne & A Langley (International Unit, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne), based on unpublished Australian Education International student enrolment data sourced from the Department of Education Employment and Workplace Relations, December 1996 to December Deloitte Access Economics (2011), Broader Implications from a Downturn in International Students, Deloitte (prepared for Universities Australia), 30 June, p Hawthorne, L (2008), Migration and Education: Quality Assurance and Mutual Recognition of Qualifications Australia Report, UNESCO, Paris. 174

176 36 Hawthorne, L (2002), Qualifications Recognition Reform for Skilled Migrants in Australia: Applying Competency-Based Assessment to Overseas-Qualified Nurses, International Migration Review, Volume 40 (6): Bob Birrell, Lesleyanne Hawthorne and Sue Richardson (2006), Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra; Hawthorne, L (2011), Competing for Skills: Migration Policies and Trends in New Zealand and Australia, Department of Labour, Government of New Zealand, Wellington. 38 Birrell, B, Hawthorne, L & Richardson, S (2006). Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra, pp House Standing Committee on Health and Ageing (2011), House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors, see individual Submissions, accessed 24 August I would like to acknowledge the generous data provision from the Centre for Adult Education (Victoria) which administers the OET, in particular the comprehensive assistance provided by Alison Deacon. 41 House Standing Committee on Health and Ageing (2011), House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors, see individual Submissions, accessed 24 August Australian Medical Council (2011), Submission to the House of Representatives Standing committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors, Australian Medical Council, Canberra, 4 February. 43 Hawthorne, L, Hawthorne, G & Crotty, B (2007), The Registration and Training Status of Overseas Trained Doctors in Australia, Department of Health and Ageing, Commonwealth of Australia, Canberra, AD007E McLean, R, & Bennett, J (2008), Nationally Consistent Assessment of International Medical Graduates, Medical Journal of Australia, 188: Frank, I (2011), Presentation and comment provided at the Canada-Australia Round Table on Mutual Qualifications Recognition, Canada Public Policy Forum, Melbourne, April. 46 Hawthorne, L (2002), Qualifications Recognition Reform for Skilled Migrants in Australia: Applying Competency-Based Assessment to Overseas-Qualified Nurses, International Migration Review, Volume 40 (6): 55-92, Geneva;; Hawthorne, L (2001), The Globalisation of the Nursing Workforce: Barriers Confronting Overseas-Qualified Nurses in Australia, Nursing Inquiry, Vol 8 (4): , Blackwell Science. 47 Hawthorne, L (2008), Migration and Education: Quality Assurance and Mutual Recognition of Qualifications Australia Report, UNESCO, Paris. 48 Australian Institute of Health and Welfare (2006), Dental Labour Force Projections, , Australian Institute of Health and Welfare, University of Adelaide, and Australian Research Centre for Population Oral Health, p Australian Pharmacy Council Limited (2010), Australian Pharmacy Council Limited Annual Report July 2009-June 2010, accessed 8 April See Chapter 1, Canadian Issues (2007), Foreign Credential Recognition, Special Edition, Spring, Ottawa. 175

177 51 Pigou, P (2008), Data presented on International Medical Graduates in New Zealand, New Zealand Health Regulation Symposium, May, Auckland. 52 Scott, B (1989), A Profile of Overseas-Qualified Nurses Seeking Registration in Western Australia and Identification of Common Problems as Perceived by Applicants, Working Party for Bridging Training Arrangements for Overseas Qualified Nurses, Perth; Hawthorne, L (2002), Qualifications Recognition Reform for Skilled Migrants in Australia: Applying Competency- Based Assessment to Overseas-Qualified Nurses, International Migration Review, Volume 40 (6): 55-92, Geneva. 53 Department of Education Employment and Workplace Relations (2011), 2009 VET FEE_HELP Statistical Report, DEEWR FEE_HELP website, accessed 24 August Hawthorne, L (2010), Demography, Migration and Demand for International Students, Chapter Five in Globalization and Tertiary Education in the Asia-Pacific The Changing Nature of a Dynamic Market, ed C Findlay and W Tierney, World Scientific Press, Singapore, pp Birrell, B (2011), Australia s New Health Crisis Too Many Doctors, Centre for Population and Urban Research Report September, Monash University, Clayton. Birrell argues, given the upscaling of domestic supply, and the enormous stock of IMGs already in Australia, it is urgent that this stock not be augmented any further through additional migration (p. v). 56 See eg Australian Institute of Health and Welfare (2011), Medical Labour Force 2009, Australian Institute of Health and Welfare, Nursing and Midwifery Labour Force 2009, Oral Health Practitioners in Australia 2006, 57 Australian Health Ministers Conference (2004), National Health Workforce Strategic Framework, Australian Health Ministers, April, Canberra; National Health Workforce Taskforce (2009), Health Workforce in Australia and Factors for Current Shortages, KPMG, Melbourne. 58 Hawthorne, L, Birrell, B & Young, D (2003), The Retention of Overseas Trained General Practitioners in Regional Victoria, Rural Workforce Agency Victoria, Melbourne. 59 Rural Workforce Agency, Victoria (2011), Submission to House of Representatives Standing Committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors, Rural Workforce Agency, Victoria, Melbourne, p Betts, C (1994), Medical Students and the Changing Make Up of the Australian Medical Workforce, People and Place, Vol 2 (2), p See for example Dobson, I (1997), The Vietnamese Presence in Australian Higher Education, Paper presented at the Maribyrnong Hoi Conference, Melbourne, 6 February 1997; Dobson, I (1998), Overseas Students in Australian Higher Education: Trends to 1996, People and Place, Vol 5(1), pp ;; Dobson, I, Birrell, R. & Rapson, V. (1997), The Participation of Non- English Speaking Background Persons in Higher Education, People and Place, Vol 4(1), pp I would like to gratefully acknowledge this section is based on my detailed analysis of skilled migration trends for a recent study commissioned by the New Zealand and Australian governments, with publication details as follows: Hawthorne, L (2011), Competing for Skills Migration Policy Trends in New Zealand and Australia Full Report, Department of Labour, Government of New Zealand, Wellington (8 June). Given the currency of the data, text has been extended rather than otherwise changed. 63 These data are derived from the 2006 Census. By definition Census counts include a large number of non permanent residents (most students and temporary labour migrants on a 457 visa), as well as New Zealanders. 64 Productivity Commission (2005), Australia s Health Workforce: Productivity Commission Position Paper, Commonwealth of Australia; Australian Institute of Health and Welfare (2004a), 176

178 Medical Labour Force, Australian Institute of Health and Welfare, Canberra; Australian Institute of Health and Welfare (2004b), Nursing and Midwifery Labour Force, Australian Institute of Health and Welfare, Canberra; Australian Institute of Health and Welfare (2010), Medical Labour Force 2008, Australian Institute of Health and Welfare, Canberra. 65 Colebatch, T (2011), Asian Migrants to Top Melting Pot, The Age, 17 June, p Colebatch, T (2011), Asian Migrants to Top Melting Pot, The Age, 17 June, p Department of Immigration and Citizenship (2009), Settler Arrivals , Commonwealth of Australia, Canberra, Table 1.2 (pp 4-5); Department of Immigration and Citizenship (2009), Emigration , Commonwealth of Australia, Canberra, Table 3 (pp 8-9); Department of Immigration and Citizenship (2010), Population Flows Immigration Aspects , Department of Immigration and Citizenship, Canberra. 68 Department of Immigration and Citizenship (2009), Fact Sheet 20 Migration Program Planning Levels, accessed 19/05/2010, 69 Australian Institute of Health and Welfare (2010), Australia s Health 2008, Australian Institute of Health and Welfare, Canberra, p See Sections 2 and 3 for skilled migration policy detail. 71 Please note that both primary applicants (PA s) as well as secondary applicants (accompanying family members) are counted in skilled migration totals by Australia. The tables in this report identify when data concerning PA s only are presented. At a number of times throughout the text where data on skilled category totals are presented, this is defined. 72 Cully, M (2009), The Effectiveness of Australia s Points-Tested Skilled Entry System and Attachment Occupational Targeting in Selection of Skilled Migrants, Speech at Migration Advisory Committee International Conference on Skilled Migration, 7 September 2009, UK: London. 73 The Australian Linked/ Australian Sponsored categories admitted skilled migrants with close family links to Australia, through a slightly reduced points-based selection compared to the Independent program with bonus points also allocated for family relationship. The State-Territory GSM programs admitted a wide range of primary applicants through a far more liberalized entry scheme, associated with significantly reduced human capital requirements. For detail on GSM sub-categories see Chapter One, Birrell, B, Hawthorne, L & Richardson, S (2006), Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra. 74 Hawthorne, L (2011), Competing for Skills: Migration Policies and Trends in New Zealand and Australia, Government of New Zealand, Wellington, 184 pp. 75 Please note that UK migrants were far more likely to migrate with accompanying family members than onshore former international students (eg from India and China). 76 Organization for Economic Cooperation and Development (2006), International Migration Outlook, SOPEMI 2006, OECD Publishing, Paris. 77 Lowell, L (2001), Skilled Temporary and Permanent Immigrants in the United States, Population Research and Policy Review Vol 20, p Khoo, S-E, McDonald, P, Voigt-Graf, C & Hugo, G (2007), A Global Labour Market: Factors Motivating the Sponsorship and Temporary Migration of Skilled Workers to Australia, International Migration Review, Vol 41 Number 2 (Summer), pp Citizenship and Immigration Canada (2010), 2009 Compared to 2000 Immigration Statistics, and accessed 24 January As A. Sweetman notes, by definition an employer is interested not only in the skills of the worker but also the cost to employ that worker. See McDonald, T, Ruddick, E, Sweetman, A & Worswick, C (2010), Introduction to Current Canadian Issues in the Economics of Immigration, 177

179 Chapter 1, in McDonald, T, Ruddick, E, Sweetman, A & Worswick, C (Eds), Canadian Immigration Economic Evidence for a Dynamic Policy Environment, McGill-Queen s University Press, Montreal and Kingston, p McDonald, P, Khoo, S-E & Hugo, G (2005), Temporary Skilled Migrants Employment and Resident Outcomes, Department of Immigration and Citizenship, Canberra; Maley, P (2008), Skill Migrant Visas Up by 24 Per Cent, The Australian, 23 July 2008, p Cully, M (2009), Invited Department of Immigration and Multicultural Affairs paper on Recent Trends in Australia s Skilled Migration Program, United Kingdom Migration Advisory Committee International Conference 82, London (September). 83 Department of Immigration and Multicultural Affairs (2005), Sponsoring a Temporary Overseas Employee to Australia, Booklet No. 11, November, p Australian Medical Workforce Advisory Committee (2005), The General Practice Workforce in Australia: Supply and Requirements to 2013, AMWAC Report , August, Sydney; Hawthorne, L, Hawthorne, G & Crotty, B (2007) The Registration and Training Status of Overseas Trained Doctors in Australia, Department of Health and Ageing, Canberra, AD007E House Standing Committee on Health and Ageing (2011), House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors, see all Submissions plus the Public Hearings and final Report, accessed 24 August House Standing Committee on Health and Ageing (2011), House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors, see individual Submissions, accessed 24 August 2011, Submission 05 (Bulgarian doctor). 87 Hawthorne, L, Birrell, B & Young, D (2003), The Recruitment and Retention of Migrant Doctors in Regional Victoria, Rural Workforce Agency, Victoria, Melbourne. 88 For a range of early analyses, see Australian Medical Workforce Advisory Committee (AMWAC), Draft: The General Practice Workforce in Australia: Supply and Requirements , AMWAC Report , August 2000; AMWAC, Temporary Resident Doctors in Australia, June 1999; AMWAC, Medical Workforce Supply and Demand in Australia A Discussion Paper, AMWAC Report , Canberra, October 1999; AMWAC, Australian Medical Workforce Benchmarks, January See eg Public Health Foundation of India (2009), Country Report: India, Public Health Foundation of India, New Delhi, September; OECD (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD, Paris; World Health Organization (2006), Working Together for Health, WHO, Geneva. 90 Hawthorne, L (2010), How Valuable is Two-Step Migration? Labour Market Outcomes for International Student Migrants to Australia, Special Edition, Asia-Pacific Migration Journal, Vol 19 No 1: Bob Birrell, Lesleyanne Hawthorne and Sue Richardson, Evaluation of the General Skilled Migration Categories (Canberra: Commonwealth of Australia, 2006), Department of Immigration and Citizenship, Settler Arrivals (Canberra: Department of Immigration and Citizenship, 2010): 3; for a detailed analysis see Mark Cully, The Contribution of Migrants to Regional Australia (Canberra: Department of Immigration and Citizenship, 2011). 93 Bob Birrell, Lesleyanne Hawthorne and Sue Richardson (2006), Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra, Chapters 1 and

180 94 See for example Strasser, R, Hays, R, Kamien M & Carson, D (2000), Is Australian General Practice Changing? Findings from the National Rural General Practice Study, Australian Journal of Rural Health, vol. 8, no 4;; Wilkinson, D (2001), Selected Demographic, Social and Work Characteristics of the Australian General Medical Practitioner Workforce: Comparison of Capital Cities with Regional Areas, Australian Journal of Rural Health, vol. 9, no. 1; Humphreys, J, Jones, J, Hugo, G, Bamford, E and Taylor, D (2001), A Critical Review of Rural Medical Workforce Retention in Australia, Australian Health Review, vol. 24. no. 4; Simmons, D, Bolitho, L, Phelps, G, Ziffer, R & Disher, G (2002), Dispelling the Myths About Rural Consultant Physician Practitioners: Victorian Physicians Survey, Medical Journal of Australia, vol. 176, no. 10;; Humphreys, J, Jones, M, Jones, J & Mara, P (2002), Workforce Retention in Rural and Remote Australia: Determining the Factors that Influence Length of Practice, Medical Journal of Australia, vol. 176, no. 10; Wilkinson, D, Symon, B, Newbury, J & Marley, J (2001), Positive Impact of Rural Academic Family Practices on Rural Recruitment and Retention in South Australia, Australian Journal of Rural Health, vol. 9, no Government of South Australia, General Skilled Migration (Adelaide: Department of Trade and Economic Development, 2010): Joyce, C et al (2007), Riding the Wave: Current and Emerging Trends in Graduates from Australian University Medical Schools, Medical Journal of Australia, Vol 186 (6) ; see also Joyce, C, McNeil, J & Stoelwinder, J U (2006), More Doctors, But Not Enough: Australian Medical Workforce Supply , Medical Journal of Australia, Vol 184 (8). 97 D. L. Scammon, S. D. Williams and L. B. Li, op cit, Department of Health and Aged Care (2000), Medical Rural Bonded Scholarships Information Pack, Commonwealth of Australia, October, Canberra. 99 Rural Australia Medical Undergraduate Scholarships (2010), Scholarships for Rural Students Studying Medicine, ACT. 100 Iredale, R (2010), The Australian Labor Market for Medical Practitioners and Nurses: Training, Migration and Policy Issues, Asian and Pacific Migration Journal, Vol 19, no. 1; Worley, P (2000), Why We Should Teach Undergraduate Medical Students in Rural communities, Medical Journal of Australia, Vol 172, No Department of Health and Aged Care (2000), Rural Australian Medical Undergraduate Scholarship Scheme, Commonwealth of Australia, July, Canberra. 102 Department of Health and Aged Care (2001), A Guide to New Rural Services, Commonwealth of Australia, Canberra. 103 Australian Health Ministers Conference (2004), National Health Workforce Strategic Framework, Australian Health Ministers Conference, Canberra, p Australian Institute of Health and Welfare (2010), Australia s Health 2008, Australian Institute of Health and Welfare, Canberra, p. 437, Australian Medical Workforce Advisory Committee (2005), The General Practice Workforce in Australia: Supply and Requirements to 2013, AMWAC Report , Sydney; Australian Health Workforce Advisory Committee (2006), The Australian Allied Health Workforce: An Overview of Workforce Planning Issues, AHWAC Report , Sydney. 106 See Productivity Commission (2005), Australia s Health Workforce: Productivity Commission Position Paper, Commonwealth of Australia; Council of Australian Governments (2006), Council of Australian Governments Communique, 14 July, Canberra; Australian Institute of Health and Welfare (2010), Australia s Health 2008, Australian Institute of Health and Welfare, Canberra, p Medical Deans of Australasia (2011), HWA Taps into Data to Plan Australia s Future, Outcomes, Issue 5, July, p

181 108 Australian Institute of Health and Welfare (2011), Medical Labour Force 2009, see Tables 5, 9, B1, and A2, Australian Institute of Health and Welfare, and p. 9 of 14 for Explanatory Notes of the Medical Workforce. 109 Birrell, B (2011), Australia s New Health Crisis Too Many Doctors, CPUR Research Report, September, Monash University, Clayton, p Since 1998 L Hawthorne has secured annual specified datasets from DEEWR (formerly DEST) carefully coded to capture all school leaver and graduate entry students enrolled in Australian entry to practice medical degrees, as well as allied health courses. These data are reported in Section 7 of this report (Tables 39 and 40). A range of lower estimates are in circulation, which should be contested. For example a recent dataset circulated by the Medical Deans of Australasia appeared to contain a serious underestimate of the number of Canadian students enrolled, at a time when 103 commenced in Semester at the University of Queensland alone, with strong enrolments also in a wide range of other graduate entry courses. 111 Since 1998 L Hawthorne has secured annual specified datasets from DEEWR (formerly DEST) carefully coded to capture all school leaver and graduate entry students enrolled in Australian entry to practice medical degrees, as well as allied health courses. These data are reported in Section 7 of this report (Tables 39 and 40). A range of lower estimates are in circulation, which should be contested. For example a recent dataset circulated by the Medical Deans of Australasia appeared to contain a serious underestimate of the number of Canadian students enrolled, at a time when 103 commenced in Semester at the University of Queensland alone, with strong enrolments also in a wide range of other graduate entry courses. 112 Quoted from Hawthorne, L (2012 forthcoming), Doctors and Migration, in Encyclopedia of Global Human Migration, Editors Immanuel Ness, Marlou Schrover, Alex Julca, Peter Bellwood, Hyekyung Lee, Donna Gabaccia Saër Maty Bâ, Aristide Zolberg, Dirk Hoerder, Steven Castles, Greta Gilbertson, Manolo Abella, Wiley-Blackwell, USA. For key references see for example World Health Organisation (2006), Working Together for Health The World Health Report 2006, WHO, Geneva; Zurn, P & Dumont, J-C (2008), The Looming Crisis in the health Workforce How Can OECD Countries Respond?, OECD Health Policy Studies, Paris. 113 Birrell, B, Hawthorne, L & Rapson, V (2003), The Outlook for Surgical Services in Australasia, Royal Australasian College of Surgeons, Melbourne. 114 Department of Health (2005), Data defining numbers of doctors (specialists and generalists) by country of qualification, 2005, National health Service, England, accessed February Medical Council of New Zealand (2009), Medical Council of New Zealand Annual Report 2009, Medical Council of New Zealand, Wellington, pp. 2, Mullan, F (2005). The Metrics of the Physician Brain Drain, New England Journal of Medicine, Vol 353 Issue 17, October 27; Arnold, P (2011), A Unique Migration South African Doctors Fleeing to Australia, CreateSpace, USA;; Ogilvie, L et al (2007), The Exodus of Health Professionals from Sub-Saharan Africa: Balancing Human Rights and Societal Needs in th Twenty-First Century, Nursing Enquiry, Vol 14 Number Mick, S, Lee S, & Wodchis, W (2000), Variations in Geographical Distribution of Foreign and Domestically-Trained Physicians in the United States, Social Science Medicine, Jan, 50 (2): Hawthorne, L, Hawthorne, G & Crotty, B (2007), The Registration and Training Status of Overseas Trained Doctors in Australia, Department of Health and Ageing, Commonwealth of Australia, Canberra, AD007E

182 119 Englmann, B & Muller, M (2007), Brain Waste Die Anerkennung von auslandischen Qualifikationen in Deutschland, Tur an Tur Integrationsprojekts ggmbh, TP Global Competences, Germany; Herfs, P (2011), International Medical Graduates in the Netherlands a Future of Medical Doctors or Cleaners?, Verlag Dr. Muller GmbH & Co, Deutschland. 120 Mullan, F (2005). The Metrics of the Physician Brain Drain, New England Journal of Medicine, Vol 353 Issue 17, October 27, p. 1812; Zun, P & Dumont, J-P (2008), Health Workforce Migration Can New Zealand Compete?, OECD Health Working Papers, OECD, Paris. 121 World Health Organisation (2006), Working Together for Health The World Health Report 2006, WHO, Geneva; Zurn, P & Dumont, J-C (2008), The Looming Crisis in the health Workforce How Can OECD Countries Respond?, OECD Health Policy Studies, Paris. 122 Organisation for Economic Co-Operation and Development (2007), International Migration Outlook, SOPEMI Annual Report 2007, OECD, Paris, pp Australian Institute of Health and Welfare (2008), National Labour Force Series Number 40: Medical Labour Force 2005, Canberra. 124 Department of Immigration and Citizenship (2011), Migration Program, Department of Immigration and Citizenship website accessed 18 June 2011, Canberra. 125 Department of Immigration and Citizenship (2011), Migration Program, Department of Immigration and Citizenship website accessed 18 June 2011, Canberra, p Hawthorne, L (2008), The Impact of Economic Selection Policy on Labour Market Outcomes for Degree-Qualified Migrants in Canada and Australia, Institute for Research on Public Policy, Vol 14 No 5, 2008, Ottawa, pp 1-50; and Hawthorne, L (2007), Labour Market Outcomes for Migrant Professionals: Canada and Australia Compared, Citizenship and Immigration Canada, Ottawa, 2007, 150pp, House Standing Committee on Health and Ageing (2011), House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors, see all Submissions plus the Public Hearings and final Report, accessed 24 August Hawthorne, L (2008), Migration and Education: Quality Assurance and Mutual Recognition of Qualifications Australia Report, UNESCO, Paris. 129 Department of Immigration and Multicultural Affairs (1999), Review of the Independent and Skilled-Australian Linked Categories, DIMA, Canberra, p Hawthorne, L & Birrell, R (2002), Doctor Shortages and Their Impact on the Quality of Medical Care in Australia, People and Place Vol 10 No 3: The annual arrival figures here are derived from Department of Immigration and Citizenship (2010), Population Flows Immigration Aspects, Edition, Department of Immigration and Citizenship, Canberra: p. 67. Please note the lower figure of 2,880 medical arrivals for was provided by DIAC in the 457 occupations table for this study. 132 Rural Workforce Agency, Victoria (2010), RWAV 2010 Policy and Outreach Services, Rural Workforce Agency, Victoria, Melbourne, accessed June 2011; Health Workforce Queensland (2010), Medical Practice in Rural and Remote Queensland: Queensland Minimum Data Set Report, 30 December, Brisbane;; Rural Health West (2010), Minimum Data Set Report and Workforce Analysis Update, November, Rural Health West, Perth;; Department of Health Western Australia (2007), Engaging Rural Doctors Final Report 2007, Department of Health, Government of Western Australia, Perth. 132 Rural Health West (2010), Minimum Data Set Report and Workforce Analysis Update, November, Rural Health West, Perth. 181

183 133 Bob Birrell, Lesleyanne Hawthorne and Sue Richardson (2006), Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra; Hawthorne, L (2011), Competing for Skills: Migration Policies and Trends in New Zealand and Australia, Department of Labour, Government of New Zealand, Wellington. 134 Department of Immigration and Citizenship (2009), Fact Sheet: The Continuous Survey of Australia s Migrants, DIAC, Canberra. 135 Hawthorne, L (2001), The Globalisation of the Nursing Workforce: Barriers Confronting Overseas-Qualified Nurses in Australia, Nursing Inquiry, Vol 8 (4): , Blackwell Science. 136 Hawthorne, L (2001), The Globalisation of the Nursing Workforce: Barriers Confronting Overseas-Qualified Nurses in Australia, Nursing Inquiry, Vol 8 (4): , Blackwell Science. 137 Hawthorne, L (2002), Qualifications Recognition Reform for Skilled Migrants in Australia: Applying Competency-Based Assessment to Overseas-Qualified Nurses, International Migration Review, Volume 40 (6): Australian Pharmacy Council (2010), Australian Pharmacy Council Annual Report, Australian Pharmacy Council, Canberra. 139 Department of Health and Ageing (2008), National Accreditation and Registration Scheme, accessed 27 December 2010; Australian Health Practitioner Regulation Agency (2010), Website, accessed 27 December Australian Health Workforce Ministerial Council (2010), Health Ministers Announce Approval of National Health Practitioner Registration Standards, 1 April, Canberra, pp Birrell, B, Hawthorne, L & Richardson, S (2006). Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra, pp Arkoudis, S, Hawthorne, L, Baik, C, Hawthorne, G, O Loughlin, K, Bexley, E, & Leach, D (2009), Key Factors Influencing the English Language Proficiency, Workplace Readiness and Employment Outcomes of International Students, Department of Employment, Education and Workplace Readiness, Canberra, McNamara, T (1996) Measuring Second Language Performance, Longman, London & New York. 144 Committee to Advise on Australia s Immigration Policy (1988), Immigration - a Commitment to Australia, Australian Government Publishing Service, Canberra, p Blacket R Foreign Medical Graduates: The Experience of the Australian Medical Examining Council and the Australian Medical Council, Implications for Medical Immigration and the Medical Workforce, The Medical Journal of Australia, Vol 153, August 6, pp This extract is from one of many interviews conducted by L Hawthorne at Australian overseas posts in relation to health workforce migration in 1996, in the course of a range of research projects. 147 Hawthorne, L (2002), Qualifications Recognition Reform for Skilled Migrants in Australia: Applying Competency-Based Assessment to Overseas-Qualified Nurses, International Migration Review, Volume 40 (6): House Standing Committee on Health and Ageing (2011), House of Representatives Inquiry into Registration Processes and Support for Overseas Trained Doctors, see individual Submissions, accessed 24 August I would like to sincerely acknowledge the generous data provision from the Centre for Adult Education (Victoria) which administers the OET, in particular the comprehensive assistance provided by Alison Deacon. 182

184 150 Centre for Adult Education (2011), OET Frequently Asked Questions, accessed 2 August; Nursing and Midwifery Board of Australia (2011), English Language Skills Registration Standard, Australian Health Practitioner Regulation Agency, Melbourne. 151 Department of Immigration and Citizenship (2010), Introduction of a New Points Test, accessed 27 December Lane, B (2011), New Rival in English Testing, The Australian Higher Education Supplement, May 25, p Birrell, B, Hawthorne, L & Richardson, S (2006), Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra, p Australian Broadcasting Commission (2011), Language Barriers, Background Briefing 22 May, Birrell, R & Hawthorne, L (1997), Immigrants the Professions in Australia, Centre for Population and Urban Research, Monash University, Melbourne. 156 Boulet, J, Bede, J, McKinley, D & Norcini, J (2005), An Overview of the World s Medical Schools, Paper delivered at the Association for Medical Education in Europe Conference, Amsterdam, September. 157 Rural Workforce Agency, Victoria (2011), Submission to Finance and Public Administration References Committee for the Inquiry into the Administration of Health Practitioner Registration by the Australian Health Practitioner Regulation Agency, Rural Workforce Agency, Victoria, Melbourne, p Birrell, B (2011), Australia s New Health Crisis Too Many Doctors, CPUR Research Report, September, Monash University, Clayton, p. v. 159 Hawthorne, L & Birrell, R (2002), Doctor Shortages and Their Impact on the Quality of Medical Care in Australia, People and Place Vol 10 No 3: See for example Kunz E (1975), The Intruders: Refugee Doctors in Australia, ANU Press, Canberra.; Iredale R (1987), Wasted Skills: Barriers to Migrant Entry to Occupations in Australia, Ethnic Affairs Commission of NSW, Sydney; Human Rights and Equal Opportunity Commission (HREOC) (1992), The Experience of Overseas Medical Practitioners in Australia: An Analysis in the Light of the Racial Discrimination Act 1975, HREOC, Sydney; Human Rights and Equal Opportunity Commission (1995), Human Rights and Equal Opportunity Commission Racial Discrimination Act 1975: Reasons for Decision of Sir Ronald Wilson, Commissioner Elizabeth Hastings and Commissioner Jenny Morgan, unpublished papers, Melbourne; Australian Medical Workforce Advisory Committee (1996), Australian Medical Workforce Benchmarks, Canberra, January;; Hawthorne, L & Toth, J (1996), The Impact of Language Testing on the Registration of Overseas Trained Doctors, People and Place, 4 (3): 47-54; Australian Medical Workforce Advisory Committee (1999), Temporary Resident Doctors in Australia, June; Australian Medical Workforce Advisory Committee (1999), Medical Workforce Supply and Demand in Australia A Discussion Paper, AMWAC Report , Canberra, October; Australian Medical Workforce Advisory Committee (2000), Draft: The General Practice Workforce in Australia: Supply and Requirements , AMWAC Report , August;; Worley, P (2000), Why We Should Teach Undergraduate Medical Students in Rural communities, Medical Journal of Australia, Vol 172, No 12; Strasser RP, Hays RB, Kamien M & Carson D (2000), Is Australian General Practice Changing? Findings from the National Rural General Practice Study, Australian Journal of Rural Health August, Vol 8 No 4; D. Wilkinson (2001), Selected Demographic, Social and Work Characteristics of the Australian General Medical Practitioner Workforce: Comparison of Capital Cities with Regional Areas, Australian Journal of Rural Health, vol. 9, no. 1; J. Humphreys, J. Jones, G. Hugo, E. Bamford and D. Taylor (2001), A Critical Review of Rural Medical Workforce Retention in Australia, 183

185 Australian Health Review, vol. 24. no. 4; D. Simmons, L. E. Bolitho, G. J. Phelps, R. Ziffer and G. J. Disher (2002), Dispelling the Myths about Rural Consultant Physician Practitioners: Victorian Physicians Survey, Medical Journal of Australia, vol. 176, no. 10; J. S. Humphreys, M. P. Jones, J. A. Jones and P. R. Mara (2002), Workforce Retention in Rural and Remote Australia: Determining the Factors that Influence Length of Practice, Medical Journal of Australia, vol. 176, no. 10;; Hawthorne, L & Birrell, R (2002), Doctor Shortages and Their Impact on the Quality of Medical Care in Australia, People & Place Vol 10 No 3: 55-67; Humphreys, J, Jones, M, Jones, J & Mara, P (2002), Workforce Retention in Rural and Remote Australia: Determining the Factors that Influence Length of Practice, Medical Journal of Australia May 20, Vol 176 No 10; Birrell B, Hawthorne L & Rapson V (2003), The Outlook for Surgical Services in Australasia, Royal Australasian College of Surgeons, Melbourne; Barton, D, Hawthorne, L, Singh B & Little, J (2003), Victoria s Dependence on Overseas Trained Doctors in Psychiatry, People & Place Vol 11 (1); Senate Select Committee on Medicare (2003), Medicare: Healthcare or Welfare?, Commonwealth of Australia, Canberra; Hawthorne, L, Birrell, B & Young, D (2003), The Retention of Overseas Trained Doctors in General Practice in Regional Victoria, Rural Workforce Agency, Victoria, Melbourne; Birrell, B & Hawthorne, L (2004), Medicare Plus and Overseas-Trained Medical Doctors, People and Place Vol 12 (2): 83-99; Mullan, F (2005), The Metrics of the Physician Brain Drain, New England Journal of Medicine, No. 353 Vol 17, October 27, ; Australian Medical Workforce Advisory Committee (2005), The General Practice Workforce in Australia: Supply and Requirements to 2013, AMWAC Report , Sydney; Australian Health Workforce Advisory Committee (2006), The Australian Allied Health Workforce: An Overview of Workforce Planning Issues, AHWAC Report , Sydney;; Australian Medical Council (2006), Nationally Consistent Assessment for International Medical Graduates, Australian Medical Council, (accessed June 2010); Council of Australian Governments (2006), Council of Australian Governments Meeting, 10 February, Canberra, (accessed Jul 2010); Hawthorne, L, Hawthorne, G & Crotty, B (2007) The Registration and Training Status of Overseas Trained Doctors in Australia, Department of Health and Ageing, Canberra, AD007E1710; Bayram, C et al (2007), Clinical Activity of Overseas Trained Doctors Practsing in General Practice in Australia, Australian Health Review, Vol 31 Number 3; Pilotto, L S, Duncan, G F, & Anderson-Wurf J (2007), Issues for Clinicians Training International Medical Graduates: A Systematic Review, Med J Aust; 187: McLean, R & Bennett, J (2008), Nationally Consistent Assessment of International Medical Graduates, Med J Aust, 188: Department of Health and Ageing (2008), 'Report on the Audit of Health Workforce in Rural and Regional Australia', Commonwealth of Australia, Canberra;; Smith S D (2008), The Global Workforce Shortages and the Migration of Medical Professions: the Australian Policy Response, Aust New Zealand Health Policy; 5: 7; Department of Human Services (2009), 'A World of Expertise: Supporting International Medical Graduates in Victoria - Showcase Programme', < accessed 18 January 2010; Young, D, Wong, C, Farish, S & McGarry, H (2009), 'Analyses of GP Registrar Examination Results ', Australian General Practice Training, University of Melbourne; Iredale, R (2010), The Australian Labor Market for Medical Practitioners and Nurses: Training, Migration and Policy Issues, Asian and Pacific Migration Journal, Vol 19, no. 1; (Please note in addition the wide range of publications which followed the notorious Jayant Patel case and subsequent legal proceedings, in relation to practices at Bundaberg in Queensland. See for example Harvey, 184

186 K & Faunce, T (2006), 'A Critical Analysis of Overseas-Trained Doctor (OTD) Factors in the Bundaberg Base Hospital Surgical Inquiry', Law in Context, Vol. 23 Number 3; Davies Report (2005), Queensland Public Hospitals Commission of Inquiry Report, State of Queensland, Brisbane.) 161 Boulet, J, Bede, J, McKinley, D & Norcini, J (2005), An Overview of the World s Medical Schools, Paper delivered at the Association for Medical Education in Europe Conference, Amsterdam, September. 162 Hawthorne, L, Hawthorne, G & Crotty, B (2007), The Registration and Training Status on Overseas Trained Doctors in Australia, Department of Health and Ageing, Canberra, Chapter Three. 163 Hawthorne, L, Hawthorne, G & Crotty, B (2007) The Registration and Training Status of Overseas Trained Doctors in Australia, Department of Health and Ageing, Canberra, AD007E OECD (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD Health Policy Studies, Organisation for Economic Cooperation and Development, Paris; World Health Organization (2006), Working Together for Health The World Health Report 2006, WHO, Geneva. 165 Bayram, C et al, Clinical Activity of Overseas-Trained Doctors Practising in General Practice in Australia, Australian Health Review, Vol 31 (3), p Australian Medical Council (2011), Submission to the House of Representatives Standing committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors, Australian Medical Council, Canberra, 4 February. 167 Young, D, Wong, C, Farish, S & McGarry, H (2009), 'Analyses of GP Registrar Examination Results ', Australian General Practice Training, University of Melbourne. 168 McLean, R, & Bennett, J (2008), Nationally Consistent Assessment of International Medical Graduates, Medical Journal of Australia, 188: Australian Medical Council (2011), Submission to the House of Representatives Standing committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors, Australian Medical Council, Canberra, 4 February, p. 9; McLean, R & Bennett, J (2008), Nationally Consistent Assessment of International Medical Graduates, Medical Journal of Australia, Vol. 188: p Frank, I (2011), Presentation and comment provided at the Canada-Australia Round Table on Mutual Qualifications Recognition, Canada Public Policy Forum, Melbourne, April. 171 McLean, R & Bennett, J (2008), Nationally Consistent Assessment of International Medical Graduates, Medical Journal of Australia, Vol. 188: p Australian Medical Council (2011), Submission to the House of Representatives Standing committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors, Australian Medical Council, Canberra, 4 February, p National Health Workforce Taskforce (2009), Health Workforce in Australia and Factors for Current Shortages, KPMG, Melbourne, see text on specialist training in section 4, pp I would like to acknowledge this analysis is derived from my research on overseas trained surgeons for the study by Birrell B, Hawthorne L & Rapson V (2003), The Outlook for Surgical services in Australasia, Royal Australasian College of Surgeons, Melbourne. This included the cited interviews with a range of Australian key informants in surgery. 175 Surgical training in many countries of origin may differ significantly to that prevailing in Australasia. As a result, RACS may exempt overseas trained surgeons from Basic Surgical Training, but require them to compete with local applicants for Advanced Surgical Training 185

187 places. The necessity to do so presents permanent resident surgeons with a serious challenge. While many can secure a short-term supernumerary position, typically in locations characterised by surgical shortages, according to a range of informants it is virtually impossible for overseastrained surgeons to compete for AST places. 176 See for example Harvey, K & Faunce, T (2006), 'A Critical Analysis of Overseas-Trained Doctor (OTD) Factors in the Bundaberg Base Hospital Surgical Inquiry', Law in Context, Vol. 23 Number 3; and Davies Report (2005), Queensland Public Hospitals Commission of Inquiry Report, State of Queensland, Brisbane. 177 Katie Elkin is completing this doctoral study at the School of Population Health, university of Melbourne. Her primary supervisor is Professor David Studdert, with L Hawthorne a cosupervisor. 178 L Hawthorne wholly prepared this quoted analysis of overseas trained psychiatrists, reported in Barton D, Hawthorne L, Singh B & Little J (2003), The Contribution of Overseas Trained Psychiatrists to Mental Health Service Provision in Victoria, People & Place, Vol 11 No D. Goldberg (2000), Impressions of Psychiatry in Australia, Australasian Psychiatry, vol. 8 issue 4, December, p Australian Medical Workforce Advisory Committee (2000), The Specialist Psychiatry Workforce in Australia - Supply and Requirements , AMWAC Report , , Canberra, p Rural Workforce Agency, Victoria (2011), Submission to House of Representatives Standing Committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors, Rural Workforce Agency, Victoria, Melbourne, p Australian Nursing and Midwifery Council (2005), Unpublished research report provided to L Hawthorne by J Conroy, ANMC, Canberra. 183 Hawthorne, L (2002), Qualifications Recognition Reform for Skilled Migrants in Australia: Applying Competency-Based Assessment to Overseas-Qualified Nurses, International Migration Review, Volume 40 (6): 55-92, Geneva;; Hawthorne, L (2001), The Globalisation of the Nursing Workforce: Barriers Confronting Overseas-Qualified Nurses in Australia, Nursing Inquiry, Vol 8 (4): , Blackwell Science. 184 Hawthorne, L (2001), The Globalisation of the Nursing Workforce: Barriers Confronting Overseas-Qualified Nurses in Australia, Nursing Inquiry, Vol 8 (4): , Blackwell Science. 185 Australian Dental Council (2011), The Mission and Purpose of the ADC, Australian Dental Council, Melbourne. The same paper, by R Broadbent (March 2011), is the source of the recent registration data provided. 186 Hawthorne, L (2008), Migration and Education: Quality Assurance and Mutual Recognition of Qualifications Australia Report, UNESCO, Paris. 187 Australian Institute of Health and Welfare (2006), Oral Health Practitioners in Australia 2006, p Australian Pharmacy Council Limited (2010), Australian Pharmacy Council Limited Annual Report July 2009-June 2010, accessed 8 April Australian Physiotherapy Council (2011), Application for the Assessment of Physiotherapy Qualifications & Skills for Migration to Australia through the General Skilled Migration Program, accessed 8 April 2011; and Assessment of Equivalence of Qualification, , accessed 8 April

188 190 See Chapter 1, Canadian Issues (2007), Foreign Credential Recognition, Special Edition, Spring, Ottawa. 191 Pigou, P (2008), Data presented on International Medical Graduates in New Zealand, New Zealand Health Regulation Symposium, May, Auckland. 192 Scott, B (1989), A Profile of Overseas-Qualified Nurses Seeking Registration in Western Australia and Identification of Common Problems as Perceived by Applicants, Working Party for Bridging Training Arrangements for Overseas Qualified Nurses, Perth; Hawthorne, L (2002), Qualifications Recognition Reform for Skilled Migrants in Australia: Applying Competency- Based Assessment to Overseas-Qualified Nurses, International Migration Review, Volume 40 (6): 55-92, Geneva. 193 Department of Education Employment and Workplace Relations (2011), 2009 VET FEE_HELP Statistical Report, DEEWR FEE_HELP website, accessed 24 August See for example Buchan, J & Calman, L (2004), The Global Shortage of Registered Nurses: An Overview of Issues and Actions, The Global Nursing Review Initiative, the International Council of Nurses, Geneva; Buchan, J & Calman, L (2004), Skill Mix and Policy Change in the Health Workforce: Nurses in Advanced Roles, OECD Working Papers, DELSA/ELSA/WD/HEA(2004)8, OECD, Paris; World Health Organization (2006), Working Together for Health, WHO, Geneva; Simoens, S & Hurst, J (2006), The Supply of Physician Services in OECD Countries, OECD Health Working Papers No. 21, DELSA/ELSA/WP2/HEA(2006)1, OECD, Paris; Englmann, B & Muller, M (2007), Brain Waste Die Anerkennung von auslandischen Qualifikationen in Deutschland, Tur an Tur Integrationsprojekts ggmbh, TP Global Competences, Germany;; Asis, M (2007), Health Worker Migration: The Case of the Philippines, Scalabrini Migration Center, XII General Meeting of the Pacific Economic Cooperation Council, Sydney, 1-2 May; OECD (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD, Paris; Aiken, L & Cheung, R (2008), Nurse Workforce Challenges in the United States: Implications for Policy, OECD Health Working Papers No. 35, DELSA/ELSA/WP2/HEA(2008)2, Directorate for Employment, Labour and Social Affairs, OECD, Paris; Buchan, J, Baldwin, S & Munro, M (2008), Migration of Health Workers: The UK Perspective to 2006, OECD Health Working Papers No. 38, DELSA/ELSA/WP2/HEA(2008)5, Directorate for Employment, Labour and Social Affairs, OECD, Paris; Hazarika, I, Nair, H, Bhattacharyya, S & Gupta, D (2009), Country Report: India, Public Health Foundation of India, New Delhi; Herfs, P (2011), International Medical Graduates in the Netherlands a Future of Medical Doctors or Cleaners?, Verlag Dr. Muller GmbH & Co, Deutschland. 195 The 2006 Census employment outcomes reported for New Zealand migrants qualified in medicine, nursing and dentistry are for New Zealand and Australia-trained professionals in each field combined. Given the complete equivalence of NZ and Australian training and ESB status, this is not viewed as problematic in terms of the analysis. 196 See analysis in Hawthorne, L (2011), Competing for Skills Migration Policy Trends in New Zealand and Australia Full Report, Department of Labour, Government of New Zealand, Wellington, 8 June. 197 Hazarika, I, Nair, H, Bhattacharyya, S & Gupta, D (2009), Country Report: India, Public Health Foundation of India, New Delhi. 198 Hawthorne, L (2008), The Impact of Economic Selection Policy on Labour Market Outcomes for Degree-Qualified Migrants in Canada and Australia, Institute for Research on Public Policy, Vol 14 No 5, Ottawa. 199 OECD (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD Health Policy Studies, Organisation for Economic Cooperation and Development, Paris. 187

189 200 Hawthorne, L (2008), The Impact of Economic Selection Policy on Labour Market Outcomes for Degree-Qualified Migrants in Canada and Australia, Institute for Research on Public Policy, Vol 14 No 5, Ottawa. 201 OECD (2004), The International Mobility of Health Professionals: An Evaluation and Analysis Based on the Case of South Africa, in Trends in International Migration, SOPEMI 2003 Edition, OECD, Paris; Arnold, P (2011), A Unique Migration South African Doctors Fleeing to Australia, CreateSpace, USA. 202 Hazarika, I, Nair, H, Bhattacharyya, S & Gupta, D (2009), Country Report: India, Public Health Foundation of India, New Delhi, p.38; 203 Asis, M (2007), Health Worker Migration: The Case of the Philippines, Scalabrini Migration Center, XII General Meeting of the Pacific Economic Cooperation Council, Sydney, 1-2 May; Valenzuela, E & Caoili-Rodriguez (2008), Migration and Education Quality Assurance and Mutual Recognition of Qualifications Philippines, UNESCO, Paris. 204 Ortin, E (1994), The Exodus of Filipino Nurses: An Action Agenda. Asian Migrant 4 (4), p See De Perelta, G (1994), For Whom the School Bell Tolls, The Manila Chronicle. March 20. Manila p. 79;; Stahl, C & Appleyard R (1992), International Manpower Flows in Asia: An Overview, Asian and Pacific Migration Journal 1 (3-4). 206 Asis, M (2007), Health Worker Migration: The Case of the Philippines, XVII General Meeting of the Pacific Economic Cooperation Council, Sydney, 1-2 May. 207 Australian Pharmacy Council Limited (2010), Australian Pharmacy Council Limited Annual Report July 2009-June 2010, accessed 8 April See for example World Health Organisation (2006), Working Together for Health - The World Health Report 2006, WHO, Geneva; Zurn, P & Dumont, J-C (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD Health Policy Studies, Paris; Simoens, S & Hurst, J (2006), The Supply of Physician Services in OECD Countries, OECD Health Working Papers, Paris; OECD (2004), The International Mobility of Health Professionals: An Evaluation and Analysis Based on the Case of South Africa, in Trends in International Migration, SOPEMI 2003 Edition, OECD, Paris. 209 OECD (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD, Paris; World Health Organization (2006), Working Together for Health, WHO, Geneva. 210 Iredale, R (2010), The Australian Labor Market for Medical Practitioners and Nurses: Training, Migration and Policy Issues, Asian and Pacific Migration Journal, Vol 19, no. 1, p This trend was evident as early as See Birrell, B & Hawthorne, L (1997), Immigrants and the Professions, Centre for Urban and Population Research, Monash University, Clayton. 212 In the context of Australia s economic and mining boom, these points were later extended to include diploma and certificate level qualifications, including a wide range of trades. 213 Birrell, B, Hawthorne, L & Richardson, S (2006), Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra, 2006, 306pp, Access Economics Pty Ltd, (2009), The Australian Education Sector and the Economic Contribution of International Students, Australian Council for Private Education and Training, Melbourne. 215 Australian Education International (2010), Monthly Summary of International Student Enrolment Data Australia Year to Date March 2010, Department of Education, Employment and Workplace Relations, Australian Government, Canberra; Birrell, B & Rapson, V, (2004) 188

190 International Students Implications for Australia s Immigration Program and Higher Education System, Monash University s Centre for Population and Urban Research, Melbourne. 216 Deloitte Access Economics (2011), Broader Implications from a Downturn in International Students, Deloitte (prepared for Universities Australia), 30 June;; Healy, G (2010), Racist Proposal Slammed, The Australian Higher Education Supplement, 21 July 2010, p Vertovec, S (2002), Transnational Networks and Skilled Labour Migration, COMPAS Paper, Oxford p Hawthorne, L (2010), How Valuable is Two-Step Migration? Labour Market Outcomes for International Student Migrants to Australia, Special Edition, Asia-Pacific Migration Journal, Vol 19 No 1: 5-36; Hawthorne, L (2010), Demography, Migration and Demand for International Students, Chapter Five in Globalization and Tertiary Education in the Asia-Pacific The Changing Nature of a Dynamic Market, ed C Findlay and W Tierney, World Scientific Press, Singapore, pp Deloitte Access Economics (2011), Broader Implications from a Downturn in International Students, Deloitte (prepared for Universities Australia), 30 June, p Collins, S (2011), Enrolments Fall for International Students, The Age, p. 7, 5 August; Collins, S & Doherty, B (2011), Student Visa Applications on Slide, The Age, p. 6, 2 August; 221 Hawthorne, L & Hamilton, J (2010), International Medical Students and Migration: The Missing Dimension in Australian Workforce Planning, Medical Journal of Australia, Vol. 193, No. 5, 6 September. 222 International student enrolment data for these and subsequent sections are derived from analysis by L Hawthorne & A Langley (International Unit, Faculty of Medicine, Dentistry and Health Sciences, university of Melbourne), based on unpublished Australian Education International student enrolment data to December The information regarding Australian 2010 internship placements for applying 2009 international medical student graduates is based on advice to L Hawthorne by Peter Carver (December 2009). The information regarding New South Wales 2011 internship allocations for international students was based on advice provided to A. Song (Faculty International Unit, Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne), by the Clinical Education and Training Institute (New South Wales (April 2011). According to this officer 770 positions were available in NSW for 2011, but only about 760 were filled. 224 Birrell, B, Hawthorne, L & Richardson, S (2006), Evaluation of the General Skilled Migration Categories, Commonwealth of Australia, Canberra, p See eg Birrell, B (2006), Implications of Low English Standards Among Overseas Students at Australian Universities, People and Place, Vol 14 no 4;; Watty, K (2007), Quality in Accounting Education and Low English Language Standards Among Overseas Students: Is There A Link?, People & Place, Vol 15 No 1; Hawthorne, L (2007), Language, Employment and Further Study, Commissioned Discussion Paper for Australian Education International, Department of Education, Science and Training, Commonwealth of Australia; Arkoudis, S, Hawthorne, L, Baik, C, Hawthorne, G, O Loughlin, K, Bexley, E & Leach, D (2009), The Impact of English Language Proficiency and Workplace Readiness on the Employment Outcomes of Tertiary International Students, Department of Employment, Education and Workplace Relations, Canberra. 226 Department of Immigration and Citizenship (2007), Changes to General Skilled Migration (GSM) Frequently asked Questions, DIAC website, Australian Government, Canberra. 227 Hawthorne, L & Hamilton, J (2010), International Students and Migration: The Missing Dimension in Australian Workforce Planning?, Medical Journal of Australia, Vol.193 Issue 5: 3-6 (6 September). 228 The University of Melbourne and the University of Queensland are undertaking this research (to be completed in 2011), with L Hawthorne the team leader. 189

191 229 Hawthorne, L, Hawthorne, G & Crotty, B (2007) The Registration and Training Status of Overseas Trained Doctors in Australia, Department of Health and Ageing, Canberra, AD007E1710, pp L Hawthorne has worked with international medical and allied health students enrolled in the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne for the past 15 years. This analysis of motivation to migrate is based on formal and informal student interviews conducted in Australia and offshore (all major students source countries) throughout these years, with the formal quotes derived from taped and transcribed interviews. 231 Canadian Resident Matching Service (2010), Canadian Students Studying Medicine Abroad, Canadian Resident Matching Service, October, Toronto, p L Hawthorne has conducted annual interview programs for prospective Canadian students across four provinces during the past 5 years, interviewing hundreds of prospective students on their background and motivation to study in Australia, on behalf of the University of Melbourne. 233 Canadian Resident Matching Service (2010), Canadian Students Studying Medicine Abroad, Canadian Resident Matching Service, October, Toronto. 234 These unpublished rates were reported to L Hawthorne in May 2011 by the key Australian agency responsible for the growing Canadian medical and dental student enrolments in Australian degrees, reportedly as advised by the Director of the CaRMS service. 235 Bowmer, I (2011), Statement made at the Canada-Australia Round Table on Mutual Recognition of Qualifications, as CEO of the Medical Council of Canada, April 13-17, Melbourne. 236 World Health Organisation (2006), Working Together for Health - The World Health Report 2006, WHO, Geneva; Zurn, P & Dumont, J-C (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD Health Policy Studies, Paris; Simoens, S & Hurst, J (2006), The Supply of Physician Services in OECD Countries, OECD Health Working Papers, Paris. 237 Australian Health Ministers Conference (2004), National Health Workforce Strategic Framework, Australian Health Ministers, April, Canberra; National Health Workforce Taskforce (2009), Health Workforce in Australia and Factors for Current Shortages, KPMG, Melbourne. 238 See for example Strasser, R, Hays, R, Kamien M & Carson, D (2000), Is Australian General Practice Changing? Findings from the National Rural General Practice Study, Australian Journal of Rural Health, vol. 8, no 4; Wilkinson, D (2001), Selected Demographic, Social and Work Characteristics of the Australian General Medical Practitioner Workforce: Comparison of Capital Cities with Regional Areas, Australian Journal of Rural Health, vol. 9, no. 1; Humphreys, J, Jones, J, Hugo, G, Bamford, E and Taylor, D (2001), A Critical Review of Rural Medical Workforce Retention in Australia, Australian Health Review, vol. 24. no. 4; Wilkinson, D, Symon, B, Newbury, J & Marley, J (2001), Positive Impact of Rural Academic Family Practices on Rural Recruitment and Retention in South Australia, Australian Journal of Rural Health, vol. 9, no. 1; Simmons, D, Bolitho, L, Phelps, G, Ziffer, R & Disher, G (2002), Dispelling the Myths About Rural Consultant Physician Practitioners: Victorian Physicians Survey, Medical Journal of Australia, vol. 176, no. 10; Humphreys, J, Jones, M, Jones, J & Mara, P (2002), Workforce Retention in Rural and Remote Australia: Determining the Factors that Influence Length of Practice, Medical Journal of Australia, vol. 176, no. 10; Department of Health and Ageing (2008), 'Report on the Audit of Health Workforce in Rural and Regional Australia', Commonwealth of Australia, Canberra. 239 Han, G-S & Humphreys, J 92003), Integration and Retention of International Medical Graduates in Rural communities A Typological Analysis, Sage, p I would like to gratefully acknowledge that this short section is based on select edited extracts of text I wholly wrote, published in Hawthorne, L, Birrell, B & Young, D (2003), The Retention 190

192 of Overseas Trained General Practitioners in Regional Victoria, Rural Workforce Agency Victoria, Melbourne. 241 See for example World Health Organisation (2006), Working Together for Health - The World Health Report 2006, WHO, Geneva; Zurn, P & Dumont, J-C (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD Health Policy Studies, Paris; Simoens, S & Hurst, J (2006), The Supply of Physician Services in OECD Countries, OECD Health Working Papers, Paris. To support this research, the OECD and WHO joined forces to produce a range of country-specific case studies (published 2008). New Zealand was the major Oceania case study. 242 Zurn, P & Dumont, J-C (2008), Health Workforce and International Migration: Can New Zealand Compete?, World Health Organization and OECD, OECD Health Working Papers, DELSA/HEA/WD/HWP(2008)3, Paris. 243 Zurn, P & Dumont, J-C (2008), Health Workforce and International Migration: Can New Zealand Compete?, World Health Organization and OECD, OECD Health Working Papers, DELSA/HEA/WD/HWP(2008)3, Paris, p. 4, p Department of Labour and Statistics New Zealand (2010), Migration of Health Workers to New Zealand Context, Trends and Outcomes, Presentation at the Fifteenth International Metropolis Conference, The Hague, 6 October. 245 Medical Council of New Zealand (2009), Medical Council of New Zealand Annual Report 2009, Medical Council of New Zealand, Wellington, pp. 2, Medical Council of New Zealand (2009), Medical Council of New Zealand Annual Report 2009, Medical Council of New Zealand, Wellington, p Medical Council of New Zealand (2008), The New Zealand Medical Workforce in 2008, Medical Council of New Zealand, Wellington. 248 Association of Salaried Medical Specialists (2010), State of the Specialist Workforce Crisis in New Zealand s Public Hospitals, Issues Paper No. 1, August, Wellington, p Hawthorne, L, Birrell, B & Young, D (2003), The Retention of Overseas Trained General Practitioners in Regional Victoria, Rural Workforce Agency Victoria, Melbourne. 250 Medical Council of New Zealand (2008), The New Zealand Medical Workforce in 2008, Medical Council of New Zealand, Wellington. 251 Pigou, P (2008), Data presented on International Medical Graduates in New Zealand, New Zealand Health Regulation Symposium, May, Auckland. 252 Zurn, P & Dumont, J-C (2008), Health Workforce and International Migration: Can New Zealand Compete?, World Health Organization and OECD, OECD Health Working Papers, DELSA/HEA/WD/HWP(2008)3, Paris. 253 Department of Labour and Statistics New Zealand (2010), Migration of Health Workers to New Zealand Context, Trends and Outcomes, Presentation at the Fifteenth International Metropolis Conference, The Hague, 6 October. 254 Health Workforce Advisory Committee (2002), The New Zealand Health Workforce Framing Future Directions Discussion Document, Wellington. 255 Walker, L (2009), A Mixed Picture: The Experiences of Overseas Trained Nurses in New Zealand, New Zealand Nurses Organization, Wellington. 256 FW Workforce Information (2009), Current Status of the National Regulated Nursing Workforce 2009, Prepared for the Clinical Training Agency, Ministry of Health, New Zealand, Wellington, p Citizenship and Immigration Canada (2010) Immigration Fact Sheets and Hawthorne, L (2008), The Impact of Economic Selection Policy on Labour Market Outcomes for Degree-Qualified Migrants in Canada and Australia, Institute for Research on Public Policy, 191

193 Vol 14 No 5, 2008, Ottawa, pp 1-50; and Hawthorne, L (2007), Labour Market Outcomes for Migrant Professionals: Canada and Australia Compared, Citizenship and Immigration Canada, Ottawa, 2007, 150pp, Hawthorne, L (2008), The Impact of Economic Selection Policy on Labour Market Outcomes for Degree-Qualified Migrants in Canada and Australia, Institute for Research on Public Policy, Vol 14 No 5, 2008, Ottawa. 260 McDonald, T & Worswick, C (2010), Internal Migration Decisions of Immigrant and Non- Immigrant Physicians in Canada, Presentation at the Metropolis International Conference, the Hague, October. 261 Hawthorne, L (ed), Foreign Credential Recognition Volume, Canadian Issues, Association for Canadian Studies, Spring, Ottawa, Association for Canadian Studies, Spring, Ottawa. See in particular Chapter 1 overview (L Hawthorne) and analysis of pre-registration barriers for IMG s (D Dauphinee). 262 Mullan, F (2005). The Metrics of the Physician Brain Drain, New England Journal of Medicine, Vol 353 Issue 17, October 27; World Health Organisation (2006), Working Together for Health The World Health Report 2006, WHO, Geneva; Englmann, B & Muller, M (2007), Brain Waste Die Anerkennung von auslandischen Qualifikationen in Deutschland, Tur an Tur Integrationsprojekts ggmbh, TP Global Competences, Germany; Organization for Economic Cooperation and Development (2006), International Migration Outlook, SOPEMI 2006, OECD Publishing, Paris; Organization for Economic Cooperation and Development (2008), International Migration Outlook, SOPEMI 2008, OECD Publishing, Paris; Zurn, P & Dumont, J- C (2008), Health Workforce and International Migration: Can New Zealand Compete?, World Health Organization and OECD, OECD Health Working Papers, DELSA/HEA/WD/HWP(2008)3, Paris; Zurn, P & Dumont, J-C (2008), The Looming Crisis in the Health Workforce - How Can OECD Countries Respond?, World Health Organization and OECD, Paris; Herfs, P (2011), International Medical Graduates in the Netherlands a Future of Medical Doctors or Cleaners?, Verlag Dr. Muller GmbH & Co, Deutschland; Hazarika, I, Nair, H, Bhattacharyya, S & Gupta, D (2009), Country Report: India, Public Health Foundation of India, New Delhi; Arnold, P (2011), A Unique Migration South African Doctors Fleeing to Australia, CreateSpace, USA; Herfs, P (2011), International Medical Graduates in the Netherlands a Future of Medical Doctors or Cleaners?, Verlag Dr. Muller GmbH & Co, Deutschland. 263 Organisation for Economic Cooperation and Development (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD, Paris, p Organisation for Economic Cooperation and Development (2008), The Looming Crisis in the Health Workforce How Can OECD Countries Respond?, OECD, Paris, p Birrell, B (2011), Australia s New Health Crisis Too Many Doctors, CPUR Research Report, September, Monash University, Clayton. 266 Hawthorne, L (2010), Demography, Migration and Demand for International Students, Chapter Five in Globalization and Tertiary Education in the Asia-Pacific The Changing Nature of a Dynamic Market, ed C Findlay and W Tierney, World Scientific Press, Singapore, pp