HEALTH WORKFORCE MIGRATION TO AUSTRALIA

HEALTH WORKFORCE MIGRATION TO AUSTRALIA Policy Trends and Outcomes 2004-2010 Lesleyanne Hawthorne Professor: International Health Workforce Faculty of Medicine, Dentistry and Health Sciences Cleared for Circulation May 30 2012 Scoping Paper Commissioned by Health Workforce Australia

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Contents Acknowledgements 5 Tables. 7 List of Acronyms... 10 Executive Summary.. 12 Section 1: Australia s Skilled Migration Policy Context 40 1.1 Permanent skilled migration to Australia in the Recent Decade... 40 1.2 Temporary skilled migration and Employer/Regional Sponsorship. 47 1.3 Trends in regional Skilled Migration 52 1.4 The Role of skilled migration compared to Domestic Health workforce training 53 Section 2: Health Workforce Migration to Australia and Employment Outcomes... 58 2.1 Global demand for migrant health professionals. 58 2.2 Health workforce migration to Australia in the recent decade. 59 2.3 Medical practitioners... 66 2.4 Nurses and midwives 71 2.5 Dentists. 73 2.6 Pharmacists 75 2.7 Rehabilitation professionals.. 76 2.8 The role of AHPRA in relation to migrant health professionals 77 Section 3: The Impact of English Testing on Migrant Health Professionals.. 78 3.1 English testing requirements... 78 3.2 The impact of English language testing in the 1990s 80 3.3 The impact of English language testing 2005-2010... 82 3.4 English language testing 2011 Policy Developments.. 86 2

Section 4: Access to Vocational Registration Medicine. 89 4.1 Pre and post-migration screening. 89 4.2 Australian Medical Council assessment outcomes 1978-2005 91 4.3 IMG survey findings 2005-07 (DoHA study).. 94 4.4 AMC assessment outcomes to 2010 96 4.5 The Competent Authority pathway... 97 4.6 Additional medical registration pathways... 100 4.7 Specialist registration overview... 101 4.8 Specialist registration Surgery (case study 1)... 103 4.9 Specialist registration Psychiatry (case study 2)... 105 4.10 Conclusion... 106 Section 5: Access to Vocational Registration Allied Health.. 107 5.1 Nurse migration and assessment 107 5.2 Dentist migration and assessment.. 109 5.3 Pharmacist migration and assessment 111 5.4 Physiotherapist migration and assessment.. 112 5.5 The case for bridging courses.. 114 5.6 Conclusion... 115 Section 6: Translation to Practice? Selected Country Profiles... 116 6.1 Introduction... 116 6.2 New Zealand.. 117 6.3 United Kingdom/ Ireland... 118 6.4 South Africa... 119 6.5 India... 121 6.6 Malaysia... 122 3

6.7 China.. 123 6.8 Philippines... 125 6.9 Iran/ Iraq (Other Southern and Central Asia)... 127 6.10 Egypt.. 128 6.11 Key findings... 129 Section 7: International Students as a Health Workforce Resource... 131 7.1 International students and skilled migration the policy context... 131 7.2 International enrolments in Australian medical and allied health degrees 131 7.3 Source countries and training institutions 134 7.4 Skilled migration outcomes for former international students 136 7.5 Employment outcomes compared to domestic graduates... 140 7.6 Employment outcomes for international medical and allied health graduates compared to all other fields... 7.7 Case study former international medical students in Australia 147 7.8 Attracting and retaining international students 152 Section 8: The Challenge of Retaining Migrant Health Professionals... 153 8.1 The emigration of health professionals from Australia... 153 8.2 The hyper-mobility of international medical graduates... 155 8.3 Case study 1 - New Zealand.. 159 8.4 Case study 2 Canada... 162 8.5 Conclusion... 165 Section 9: Policy Issues and Research Priorities... 166 9.1 Key policy issues... 166 9.2 Future research priorities... 170 Endnotes and References... 172 145 4

Acknowledgements This study was commissioned by Health Workforce Australia (HWA) to assess the scale and impact of health workforce migration on Australia in recent years, including the characteristics of those most likely to proceed to professional practice. I would like to express my sincere appreciation of the following individuals, who made important contributions to the final report. Firstly, my thanks go to Mark Cormack and Ian Crettenden of HWA, with whom I regularly liaised in relation to the scope and focus of the study. I also affirm the valuable feedback received from the Honourable Jim McGinty, Chair of the HWA Board, following review of this paper s Preliminary Draft. Secondly, it has been a challenging task to secure data from an unprecedented array of sources of relevance to health workforce migration. In particular I would like to express my appreciation of the contribution made by James Inglis, Sam Tudman, Sarah Ambrose and Janine DeKorte Health Workforce Australia s in-house research staff, with whom it was a pleasure to work in relation to complex requirements. By agreement, data were requested by HWA to my specifications from a range of external bodies. Based on these data HWA staff developed a range of tables for my analysis, the exception being select 2006 Census tables I had previously prepared for UNESCO (sourced); all Occupational English Test, Graduate Destination Survey and Medical Schools Outcomes Database tables (prepared by my colleague Anna To at the University of Melbourne); Australian Medical Council data (tables provided by the AMC); and tables provided by select other regulatory bodies to the researcher (the Australian Nursing and Midwifery Council, the Australian Dental Council, and the Australian Physiotherapy Council). Thirdly, I d like to thank the following individuals from external bodies who provided statistical data and/ or key informant perspectives related to health workforce migration across the eight month period of this study. They deeply informed my understanding of the issues: David Smith, Peter Speldewinde, Michael Willard and Mark Cully (Department of Immigration and Citizenship) Ian Frank (Australian Medical Council) Dr Robert Broadbent (Australian Dental Council) Amanda Adrian and Mark Braybrook (Australian Nursing and Midwifery Council) Margaret Grant (Australian Physiotherapy Council) Lyn LeBlanc (Australian Pharmacy Council) Alison Deacon, Gerrard Neve and Josh O Connell (Centre for Adult Education Occupational English Test) Claire Austin, Sharon Kosmina and Karen Argo (Rural Workforce Agency, Victoria) Belinda Bailey (Rural Health West) 5

Dr Ian Cameron (NSW Rural Doctors Network) Chris Mitchell (Health Workforce Queensland) Margaret Proctor (National Office of Overseas Skills Recognition Australian Education International, Department of Education Employment and Workplace Relations) and Jane Press (Department of Employment, Education and Workplace Relations) Martin Fletcher, Chris Robertson and Jenny Collis (Australian Health Practitioner Regulation Agency) Ian Hawke (Tertiary Education Qualifications and Standards Agency) Sue Beitz (Skills Australia) Dr Philip Pigou (Medical Council of New Zealand) Health Workforce New Zealand (several officers) Professor Richard Bedford (Auckland University of Technology) Dr Ian Bowmer (Medical Council of Canada) Corinne Prince St-Ammand (Citizenship and Immigration Canada) Professor Arthur Sweetman (McMaster University) Nick Kominos (Medical Schools Outcomes Database and Longitudinal Tracking Project, Medical Deans Australia and New Zealand Inc.) Finally, I would like to express warm appreciation to my colleagues in the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne Anna To, for her meticulous analysis of the Occupational English Test, Graduate Destination Survey, and the Medical Schools Outcomes Databases; Associate Professor Graeme Hawthorne, for his preparation of select 2006 Census tables; Alison Langley and Anna To, for their analysis with me of 14 years of successive Department of Education Employment and Workplace Relations international student enrolment data (Australia-wide); Claudia Sandoval, for her excellent assistance in scheduling and transcribing select interviews, as well as final formatting; and the University of Melbourne Institutional Planning, Evaluation and Quality group, for permitting access to their national Graduate Destination Survey dataset for my analysis for this study. 6

Executive Summary Tables Table 1: Permanent Immigration Intakes to Australia by Major Category 15 Table 2: Permanent Health Professional Migration GSM Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10, and 2004-05 to 2009-10 Grand Total) 20 Table 3: Temporary Health Professional Migration 457 Temporary Visa Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10 Arrivals and Grand Total) 21 Full Report Tables Table 1: Participation Rates of Permanent Resident Undergraduate Medical Students in Australia aged 15 to 24 by Select Country of Birth: 1993 41 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 (2006-07 to 2007-08) 48 Table 6: Top 10 Source Countries for Migrant Health Professionals Selected Under the General Skilled Migration Program (2004-05 to 2009-10) and the 457 Temporary Program (2005-06 2009-51 10) Table 7: State/Territories of Intended Residence, Settler Arrivals 1998-99 and 2008-09 (All Fields) 52 Table 8: Australian Medical Schools Established by March 2006 54 Table 9: Medical Students by Type by Student Place: Number of Places (2006-10) 56 Table 10: Australian Medical and Allied Health Course Completions (2001-09) 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 (2001-06 Arrivals) 61 Table 13: Location of 2001-06 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 2007-08 and 2008-09) 63 Table 15: General Skilled Migration Arrivals - Health Professional Primary Applicants by Field and Place of Selection (2004-05 to 2009-10) 64 Table 16: Labour Market Outcomes for Degree-Qualified Australia/New Zealand-Born Medical Graduates, Compared to Migrant Medical Graduates Arriving 2001-2006 (2006) 66 Table 17a: Permanent Health Professional Migration GSM Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10, and 2004-05 to 2009-10 Grand 68 Total) Table 17b: Temporary Health Professional Migration 457 Temporary Visa Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10 Arrivals and Grand Total) 68 Table 18: Employment Outcomes and Profession of Primary Applicant by Field for Health Professionals Selected by Skilled Compared to Family Categories (CSAM 2008-09) 70 Table 19: Employment Status of Australia/New Zealand Degree-Qualified Nurses, Compared to Overseas-Born Nurse Arrivals 2001-2006 (2006 Census) 72 Table 20: Employment Status of Australia/New Zealand Degree-Qualified Dentists, Compared to Overseas-Born Dentist Arrivals 2001-2006 (2006 Census) 74 7

Table 21: Top 20 Source Countries for Migrant Health Professionals to Australia, Selected through the General Skilled Migration Program, Primary Applicants (2004-05 to 2009-10) 78 Table 22: Top 20 Source Countries for Migrant Health Professionals to Australia, Selected through the 457 Visa Program, Primary Applicants (2005-06 to 2009-10) 79 Table 23: Occupational English Test Pass Rates by Region of Origin, Field of Training (1991-1995) 81 Table 24: Occupational English Test Attempts by Key Field (2005-2010) 83 Table 25: Occupational English Test Outcomes by Country of Training (2005-2010) 85 Table 26: MCQ Pass Rate by Region and Age Tertile (1978-2005 Australian Medical Council Examination Candidates) 92 Table 27: Clinical Examination Pass Rate by Region and Age Tertile (1978-2005 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 (2004-2010) 97 Table 30: AMC Competent Authority Pathway Outcomes by Age of Applicant (2007-2010) 99 Table 31: AMC Competent Authority Pathway Outcomes by Top 10 countries of Training (2007-2010) 99 Table 32: AMC Specialist Assessment Pathway Outcomes by Top 10 Countries of Training (2004-2010) 101 Table 33: AMC Specialist Assessment Pathway Outcomes by Top 10 Specialties (2004-2010) 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: 1996-2009 133 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

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 (2006-2010) 142 Table 52: Employment Outcomes for former International Nursing Students in Australia Compared to Domestic Graduates four Months Following Course Completion (2006-2010) 143 Table 53: Employment Outcomes for former International Dental Students in Australia Compared to Domestic Graduates four Months Following Course Completion (2006-2010 144 Table 54: Employment Outcomes for Former International Physiotherapy Students in Australia Compared to Domestic Graduates four Months Following Course Completion (2006-2010) 145 Table 55: Median Annual salaries ($AUD) for Australian Graduates Working Full-Time in Australia by Select Field, Domestic compared to Non-Permanent Resident (2006-2010) 146 Table 56: Victorian Internship Destinations for International Students Graduating from the University of Melbourne MBBS Degree (2005-2009) 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 (2004-05 to 2009-10) 153 Table 59: Emigration of Health Professionals from Australia, by Country of Birth (2004-05 to 2009-10) 154 Table 60: Emigration of Australia-Born and Migrant Health Professionals from Australia, by State/Territory (2004-05 to 2009-10 155 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. 164 9

List of Acronyms ACRRM ADC AHMC AHPRA AMC ANMAC APC APC ATS BST CAOP CaRMS CE CSAM DEEWR DoHA DIAC ECFMG EP ESB FICPI GDS GSM HWA IDG IELTS IEN IMG LSIA MCQ MODL MSOD NESB NFEC NLF OET OTD OTP PA PB PBA PESCI PG PR RACGP RACS RWAV Australian College of Rural and Remote Medicine Australian Dental Council Australian Health Ministers Conference Australian Health Practitioner Regulation Agency Australian Medical Council Australian Nursing and Midwifery Council Australian Physiotherapy Council Australian Pharmacy Council Advanced Surgical Training Basic Surgical Trainee Competency Assessment of Overseas Pharmacist Canadian Resident Matching Service Clinical Examination Continuous Survey of Australia s Migrants Department of Employment, Education and Workplace Relations Department of Health and Ageing Department of Immigration and Citizenship Educational Commission for Foreign Medical Graduates Entry to practice English Speaking Background Fitness for Intended Clinical Practice Interview Graduate Destination Survey General Skilled Migration Health Workforce Australia International Dental Graduate International English Language Testing System Internationally educated nurses International medical graduate/s Longitudinal Survey of Immigrants to Australia Multiple Choice Questions Migration Occupations in Demand List Medical Schools Outcomes Database Non-English Speaking Countries National Forensics, Ethics and Calculations Not in labour force Occupational English Test Overseas Trained Doctor Overseas Trained Psychiatrist Primary Applicant Post Basic Pharmacy Board of Australia Pre-employment Screening Clinical Interview Post Graduate Permanent Resident Royal Australian College of General Practitioners Royal Australasian College of Surgeons Rural Workforce Agency Victoria 10

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

Executive Summary 1. Health Workforce Migration The Global Context 1.1 Global Demand for Migrant Health Professionals Eight key factors drive the global recruitment of migrant health 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 50 2. Second, health workforce migration is a panacea for short-term domestic shortages. In 2000, for example, the UK s National Health Service signed bilateral agreements with India, the Philippines and Spain to contribute to the recruitment of 9,500 medical consultants, 20,000 nurses and 6,500 allied health professionals, while domestic training was being scaled up. By 2005, in consequence, 65% of staff grade doctors, 59% of associate specialists and 43% of senior house officers were third country trained (derived from beyond the UK and the European Economic Area.) 3. Third, international health graduates are sought to compensate for sustained outmigration. In New Zealand, for example, recruitment of 2.3 million migrants in 50 years translated to a net population gain of just 208,000 people. By 2010 1,100 international medical graduates (IMG s) were being registered annually compared to just 300 domestic graduates. Fewer than half these IMG s would remain for a year, dropping to 31% within a 3 year 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

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

health professionals. In these designated areas overseas students who have completed their studies in Australia but are unable to meet the pass mark as an independent migrants may be granted a permanent visa (visa 882) 11. Three case studies illustrate the scale of demand and the significance of location. By 2010, according to the Rural Workforce Agency, Victoria, 36% of the 1,209 general practitioners (GP s) working in rural and remote Victoria had obtained their basic medical qualification outside Australia, primarily in South Asia (11%), the UK/Ireland (7%), Africa (5%), Eastern Europe (4%) and the Middle East (3%), including all vintages of arrival. As early as 2007, IMG s constituted 52% of rural and remote GP s in Western Australia, derived from 33 countries of training most notably the UK (24%), South Africa (20%), India (14%), Nigeria and the Netherlands. By 2010 this had risen marginally to 53% - double the level of reliance in 2002. In 2010, according to Health Workforce Queensland, 46% of doctors in rural and remote practice were overseas-trained - primarily qualified in the UK (20%), India (15%), South Africa (12%), the Philippines, New Zealand, Pakistan and Sri 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 1983-84 to 1994-95, for instance, 30,544 migrant nurses were accepted by Australia on either a permanent or a temporary basis. This counter-balanced the departure overseas of 23,613 nurses who were locally trained and 6,519 migrant nurses (yielding a net gain of just 412 nurses in all) 13. By 2008-09, based on analysis of Department of Immigration and Citizenship (DIAC) data, Victoria was the major importer of temporary nurses (1,010 that year), followed by Queensland (780), Western Australia (750) and NSW (610). Migrant health professionals contribution to regional and remote practice remains critical. Many also provide essential services in urban public sector sites. 2.2 Australian Skilled Migration Policy in the Recent Decade (All Fields) Australia is a global exemplar of nation-building through government planned and administered skilled, family and humanitarian migration programs. The scale of skilled migration has grown rapidly in recent years, now constituting 60% of permanent intakes14. In 2009-10 108,100 permanent migrants were selected in the General Skilled Migration (GSM) category, compared to 27,550 in 1996-97. By 2006 Australia had the world s highest percentage of foreign-born (24% of the population), followed by New Zealand (23%), Canada (20%), and the US (11%). In 2009 the population stood at 21,875,000 people, following the largest annual growth in 20 years (a net gain of 443,100 people). Immigration was the primary cause, despite domestic fertility rates rising to 2%. Between 2004-05 and 2008-09, 358,151 skilled category migrants were admitted to Australia (including dependents). Few were derived from the major English speaking background countries. Eight of Australia s top 10 GSM source countries at this time were in Asia in rank order India, China, the United Kingdom, Malaysia, Indonesia, Sri Lanka, the Republic of Korea, South Africa, Hong Kong SAR and Singapore, when English speaking background migrants constituted just 17% of the total. For 2010-11 Australia s permanent migration target was set at 190,300 people. Sixty percent of places were allocated to GSM migrants (around 118,000), 32% to the family category, and 8% to humanitarian entrants. (See Table 1.) 14

Table 1: Permanent Immigration Intakes to Australia by Major Category Program Numbers by Stream 1996-97 1998-99 2001-02 2006-07 2007-08 2008-09 2009-10 2010-11 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 97,920 108,500 115,000 108,100 113,850 Additional Skilled* c5,000 Special Eligibility 1,730 890 1,480 200 220 300 300 300 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 2011-11: Immigration, Parliament of Australia, http://www.aph.gov.au/library/pubs/rp/budgetreview2010-11/immigrationprograms.htm, accessed 21 August 2011*. An additional 100,000-110,000 migrants are selected annually on an employer-sponsored basis, through the uncapped 457 long-stay visa program which allows temporary migrants to work for up to 4 years. Temporary source countries differ substantially to those of the GSM program, reflecting employer preference. Australia s top 10 recent birthplaces have included five English speaking background countries (the UK, South Africa, the USA, Ireland and Canada), plus 2 in western Europe (Germany and France) by definition countries with directly comparable development levels and training systems. 2.3 Sub-National Competition for Skilled Migrants The global recruitment of migrant professionals constitutes one major challenge. Facilitating their dispersal across Australia is another. Like Australians, migrants habitually settle in highly skewed sites - in particular capital cities associated with jobs, settlement services, networks, ethnic infrastructure and urban amenity. (An identical pattern prevails in New Zealand and Canada.) As demonstrated by the 2006 Census analysis, 2001-06 arrivals were primarily attracted to NSW, Victoria, Queensland, and Western Australia, with few migrant professionals settling in other states. In 2008-09 NSW attracted the largest national migrant share (30% of total arrivals compared to 42% a decade earlier), followed by Victoria (25%), with rapid recent gains made by the mineral-rich states of Queensland and Western 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 2004-05 to 14,060 in 2008-09, with annual targets of 24,000 set for 2010-11 and 2011-12 (all fields) 17. By mid-2011 seven state/territory regional sub-categories existed, constituting a third of the total permanent General Skilled Migration stream. South Australia s 2010 plan, for instance, included a list of 113 preferred occupations. Virtually every health profession was sought, the great majority requiring degree-level 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

to develop skilled migration plans to be coordinated by DIAC, with skill levels and leakage across state boundaries to be monitored. 2.4 The Role of Skilled Migration in Relation to Domestic Workforce Supply The Federal government affirms skilled migration to remain a national priority for Australia in the coming period (all fields), within the following context: Long-term workforce demand will be met through greatly expanded domestic training (most notably through 40% of the youth cohort becoming bachelor degree qualified) 19. Medium-term demand will be met through the General Skilled Migration program. Short-term demand will be addressed through employer and state/ territory sponsored labour migration programs - most notably the uncapped 457 long-stay visa (where employment offers can be tied to specific locations for up to 4 years). In terms of health, the Australian Health Ministers have set a goal for domestic self-sufficiency by 2025. The policy imperative is thus to recruit migrant professionals able to contribute effectively within the next 13 years. Health Workforce Australia has been charged by the Australian Health Ministers Conference to develop a National Training Plan. Specifically, its aim is to provide: the estimated numbers of professional entry, postgraduate and specialist trainees that will be required between 2012 and 2025 to achieve self-sufficiency. Self-sufficiency is defined as a situation in which all of Australia s requirements for medical, nursing and midwifery professionals in 2025 can be met from the supply of domestically trained graduates without the need to import overseas trained doctors, nurses and midwives to meet a supply gap 20 The scale of Australia s interim dependence is high. According to the Australian Institute of Health and Welfare, for instance, by 2009 24.5% of Australia s 72,739 medically employed workforce was overseas-trained, including 6% of doctors from the UK/Ireland, 3% from New Zealand, and 16.4% (or 11,948) from other countries. The majority of these international medical graduates (all sources) were concentrated in NSW (5,829), Victoria (3,829), Queensland (3,025), Western Australia (2,858), and South Australia (1,681), with minuscule numbers practising in other territories or states. In 2008-09, based on state and territory medical board/ council data, 17,141 doctors (including IMG s) were employed under various forms of conditional registration, most notably in NSW (6,100), Victoria (3,971) and Queensland (2,803). This category covered medical practitioners not meet(ing) the requirements to become a generally registered medical practitioner. Further, 2,695 IMG s were employed through area of need registrations (primarily in Queensland, with 1,351) in a context where Australia had become disproportionately reliant on medical migrants for primary health care in outer regional and remote/ very remote 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) 22. 16

Domestic medical graduations: By 2006 8,318 Commonwealth supported students were enrolled in medical degrees, rising to 11,873 in 2010, while the number of domestic full-fee medical students doubled (from 405 to 905). In consequence domestic student graduations in medicine rose from 1,203 in 2001 to 1,915 in 2009. Domestic allied health graduations: Rapid growth has also occurred in nursing (graduations rising from 5,084 in 2001 to 7,266 in 2009) and in dentistry (164 graduations in 2007, compared to 416 by 2009, noting earlier data were not provided) 23. 3. The Study Focus 3.1 Adult Versus Child Migration Pathways Within this policy context, Australia has relied on five major sources of migrant health professionals to boost supply - the focus of the present study. As will be demonstrated, these migrants are associated with highly variable employment outcomes: 1. New Zealand health professionals Characterised by free entry to Australia and full qualification recognition under the terms of the Trans-Tasman Agreement. 2. Permanent skilled migrants - Selected as primary applicants on the basis of human capital attributes through Australia s points-tested General Skilled Migration Program. 3. Temporary labour migrants - Sponsored by employers through Australia s 457 long-stay visa program to fill designated positions for up to 4 years. 4. The dependents of skilled migrants, plus family and humanitarian category arrivals Selected in non-labour categories, arriving unfiltered in advance for human capital attributes. 5. Former international students - Qualified in Australian medical and allied health degrees, who convert status to remain through a process termed two-step migration. It is important to acknowledge that a sixth migration-related workforce resource exists, which will not be further examined here. By 2006, according to the Census analysis, 45% of Australia s medical workforce was overseas-born, compared to 53% of dentists and 25% of nursing 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

The focus of the current study is recently arrived overseas-trained migrants, in the context of rapidly accelerating recent flows. Further, the study assesses recent Australia-trained international students and their immediate workforce contribution. 3.2 Methodological Challenges A number of methodological issues should be noted in relation to the research findings: Highly variable levels of data are sought/ kept in relation to the different immigration categories. The greatest level of information (including occupational and demographic characteristics) is available for primary applicants selected in the General Skilled Migration category - migrants filtered by DIAC on the basis of their employment attributes. Far more limited data are available for GSM dependents - despite many partners having comparable education and employment skills, and an intention to work. Modest data are available for 457 visa temporary health professionals (including age and gender, and for the 2004-05 year of arrival). Very little is known of their partners, despite these being accorded the right to work. Least data are available for family and in particular humanitarian category entrants, approved for entry to Australia on the basis of relationship or perceived need. Given this, the most comprehensive source of attributes and occupational data for migrant health professionals is the Australian Census last collected by the Australian Bureau of Statistics (ABS) in 2006, and capturing all permanent as well as temporary residents. Multiple additional databases were sourced (a range never previously analysed for health workforce planning purposes). Indeed, a comprehensive analysis of health workforce immigration to Australia is long overdue. As noted in a recent assessment of health workforce supply by the Australian Institute of Health and Welfare: New entrants to the workforce are mainly from the education system and skilled immigration. Departures from the workforce include migration, resignations, retirements and death. Not all these elements of workforce supply can be accurately measured. For example current health workforce migration data are not considered to be of sufficient quality to provide a reasonable measure of this 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 1998-99 to 2008-09 221,643 New Zealanders arrived across all qualification fields. Just 69,884 departed that decade, ensuring major human resource gains to Australia. By the time of the 2006 Census 1,163 New Zealand medical practitioners were resident, along with 5,905 nurses and midwives, 196 dentists, and 1,894 other allied health professionals (9,158 health professionals across all vintages of arrival). 18

The majority of New Zealand health migrants were university educated (nursing also including 1,616 who were diploma-qualified). Many were recent arrivals, in a context where 1,247 nurses, 240 doctors, 44 dentists and 368 other allied health professionals had reached Australia from 2001 to 2006. By definition few were captured by Department of Immigration and Citizenship statistics. 4.2 Permanent General Skilled Migration Category Selection The General Skilled Migration category is Australia s second key source of migrant health professionals, admitting applicants on a permanent resident basis. Since 1999 GSM primary applicants (PA s) have been filtered in advance for human capital attributes, with those at risk of delayed or de-skilled employment excluded at point of entry through points-based selection criteria. Key measures have included: Mandatory pre-migration English language testing, with progressively higher standards required (see Section 3). Mandatory pre-migration credential assessment, conducted by the relevant Australian regulatory bodies for each vocational field (see Sections 4-5). Allocation of greatest points weighting to the core employability factors of skill, age (below 45 years) and English language ability, based on establishment of minimum threshold standards for each of these aspects. Additional points weighting for occupations in demand, in addition to degree-level qualifications correlating to specific (rather than generic) professional fields. Allocation of bonus points for former international students with credentials recently completed in Australia (a minimum of one and subsequently two years). Allocation of further bonus points for recent continuous Australian or international experience in a professional field, for a genuine job offer in an occupation in demand, for regionally-sponsored applicants (etc) 26. GSM Migration Scale by Field In 2009-10 3,940 migrant health professionals were selected as permanent GSM migrants, compared to 2,870 in 2008-09 and 2,480 in 2005-06 (with 2009-10 the peak year). From 2004-05 to 2009-10 a total of 15,940 were admitted, with key trends as follows: Medical practitioners: 1,070 selected in 2009-10 (compared to 450 in 2008-09 and just 180 in 2005-06). Nursing professionals: 1,700 selected in 2009-10 (compared to 1,360 in 2008-09 and 1,470 in 2005-06). Other health professionals: 1,170 selected in 2009-10 (compared to 1,070 in 2008-09 and 830 in 2005-06) - in particular pharmacists (560 in 2009-10), dentists (180 in 2009-10), and physiotherapists (130 in 2009-10). (See Table 2.) Major Source Countries It is important to note that 43% of recent GSM health professionals have been derived from English-speaking source countries (in marked contrast to 17% for the GSM program as a whole). Australia s top 10 source countries from 2004-05 to 2009-10 were the United Kingdom (4,960), India (1,610), Malaysia (1,470), China (1,030), South Africa (580), the Philippines (570), the 19

Republic of Korea (540), Egypt (430), Singapore (470), and Ireland (410). Most selected for admission in 2009-10 were female (63% of the total, reflecting the dominance of nursing). The majority were of prime workforce age (34% aged 25-29 years, 27% aged 30-34, and 16% aged 30-39, while 8% were new graduates aged 20-24 years). (Please note this level of demographic detail was not provided for 457 visa temporary migrants.) Table 2: Permanent Health Professional Migration GSM Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10, and 2004-05 to 2009-10 Grand Total) Select Field GSM 2005-06 GSM 2008-09 GSM 2009-10 GSM Total 2004-05 to 2009-10 Nursing 1,470 1,360 1,700 8,250 Medicine 180 450 1,070 2,330 Pharmacy 300 440 560 2,080 Dentistry 70 130 180 600 Physiotherapy 80 90 130 550 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 2005-06 to 2009-10, compared to 15,940 for the GSM from 2004-05 to 2009-10 (noting data for the GSM were available a year longer). There are compelling attractions related to the 457 visa: Temporary resident migrants are sponsored by Australian employers, with applications fast-tracked. Their location can be prescribed as a condition of visa entry (facilitating employment in areas of need ). Migrants arrive to pre-arranged work, securing immediate employment outcomes in designated positions (with 99% employment rates at 6 months the norm). Health professionals are allowed to work on a conditional or limited registration basis for up to 4 years, with age criteria far less restrictive. As described by the Department of Immigration and Citizenship, The person identified to fill a nominated vacancy must satisfy the department that they have skills which match those required for the vacancy for which they have been nominated A skill assessment of the visa applicant is not generally required (unless there are doubts about his/her capacity to fill the position). Where Australian registration or licensing is required to undertake the nominated position, applicants may be asked to provide evidence that they are eligible for the relevant registration or licence. Medical practitioners are required to provide evidence of registration to practise in the state or territory in which they will be working 27. 20

Migration Scale by Field The 457 visa option has proven highly attractive to migrants, employers and governments. In 2007-08 health and community service workers dominated the category, with 9,090 sponsored admissions (21% growth on the previous year). Australia s expansion of area of need posts in medicine has improved medical distribution to under-served sites. Workforce supply is boosted, despite debate on the conditional registration scheme, which allows thousands of temporary resident IMG s to work on a supervised basis. Temporary flows have also had a profound impact on occupational distribution relation to nursing and midwifery. In 2009-10 6,020 migrant health professionals were sponsored by Australian employers on the 457 visa, compared to 8,190 in 2008-09 and 5,300 in 2005-06. From 2005-06 to 2009-10 a total of 34,870 arrived. The scale by field was as follows, trending down from Australia s 2008-09 peak of 8,190, at a time when permanent health GSM flows were growing: Medical practitioners: 2,670 in 2009-10 (compared to 3,310 in 2008-09 and 2,120 in 2005-06). Nursing professionals: 2,710 in 2009-10 (compared to 4,070 in 2008-09 and 2,660 in 2005-06). Other health professionals: 640 in 2009-10 (compared to 800 in 2008-09 and 540 in 2005-06), in particular dentists (150 in 2009-10), physiotherapists (90 in 2009-10) and pharmacists (20 in 2009-10). (See Table 3.) Table 3: Temporary Health Professional Migration 457 Temporary Visa Category Arrivals in Rank Order by Select Field (2005-06 Compared to 2009-10 Arrivals and Grand Total) Select Field 457 Visa 2005-06 457 Visa 2008-09 457 Visa 2009-10 457 Visa Total 2005-06 to 2009-10 Nursing 2,660 4,070 2,710 15,960 Medicine 2,120 3,310 2,670 15,490 Dentistry 90 160 150 660 Physiotherapy 60 100 90 420 Pharmacy 50 20 20 160 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 2005-06 to 2009-10) in marked contrast to an extraordinary 2,080 selected from 2004-05 to 2009-10 through the General Skilled Migration category. Major Source Countries Australia s 457 visa category demonstrates the strength of employer preference for high-level English ability (including native speakers), comparable health education systems, and perceived capacity to integrate at speed. From 2005-06 to 2008-09 45% of Australia s 34,870 sponsored health professionals were derived from the major English-speaking countries (compared to 43% of the GSM). The top 10 source countries were the United Kingdom (9,350), India (6,420), the Philippines (1,850), South Africa (1,770), Malaysia (1,570), Ireland (1,560), China (1,380), Zimbabwe (1,180), Canada (950) and the United States (830). 21