The Pressure to Recognise Foreign Medical

Qualifications –

Emerging Global Trends

Lesleyanne Hawthorne

Professor – International Health Workforce

Faculty of Medicine, Dentistry and Health Sciences

International Association of Medical Regulatory Authorities Conference 2014

11th International Conference on Medical Regulation

London (9-12 September 2014)

Transformation of Global Skilled Migration -

Future Impact on Regulation?

1. Demographic contraction:

OECD and select other countries (eg Singapore, Japan)

2. Prioritisation of skilled migration:

Up to 68% of permanent intakes to Canada, Australia and New Zealand

3. 21st century mobility patterns: Transformed!

Hypermobility (eg India Gulf S Africa NZ Australia)

New directions (eg pan-Asian)

Scale of temporary flows

Individual agency (+ migration factored into career choice)

4. Migration pathways: Permanent versus temporary versus international student flows

What level of regulation is appropriate/ required?

‘One size fits all’ or alternative recognition pathways?

International medical graduates (IMGs) –

1. Bilateral/multilateral agreements (eg EU, Trans-Tasman)

2. International students (study-migration pathway)

3. Temporary sponsored migrants

4. Permanent skilled migrants

5. Partners of skilled migrants

6. Family and Humanitarian category migrants

Key Medical Migration Pathways -

Which Regulation Requirements?

Issue 1 -

Diversification of IMG Source Countries/ Regions

Challenges:

Training variability

Technological ‘fit’

Language and clinical communication skills

CASE STUDY 1: Chinese IMGs in OECD countries

CASE STUDY 2: QA and the Philippines

Growing Reliance on Migrant Professionals:

Australia (2001 & 2011) Compared to Canada (2001)

Occupation 2011 % Overseas-Born

In Australia

2001 % Overseas-Born

In Australia (compared to

Canada)

Engineering 62% 48% (50%) Computing 57% 48% (51%) Medicine 48% 46% (35%) Science 37% (36%) Commerce/ business 43% 36% (27%) Architecture 36% (49%) Accountancy 53% 36% (35%) Arts/ humanities 31% (24%) Nursing 29% 24% (23%) Education 24% 20% (15%) Source: 2001 and 2011 Census data analysis, Australia and Canada; The Impact of Economic Selection Policy on Labour Market Outcomes for Degree-Qualified Migrants in Canada and Australia, L Hawthorne, Institute for Research on Public Policy, Vol 14 No 5, 2008, Ottawa, 50pp

Growth in Permanent Medical Migration:

Australia 2006-11 (Compared to 2001-05) PLUS Temporary IMGs

Field

2001-2005 Arrivals

2006-2011 Arrivals

Medicine 7,241 12,696

Nursing 8,584 19,746

Pharmacy 1,798 3,005 Physiotherapy 755 1,556

Dentistry 1,063 2,343

Scale of Diversity: Major Source Countries/ Regions for

IMGs Migrating to Canada

Top 1996-2001 arrivals (all immigration categories): 1. China (3,587) – 4% employed in medicine in first 5 years

2. S+C Asia (3,052) – 12%

3. E Europe (2,137) – 8%

4. Other Middle East/ North Africa (1,714) – 15%

5. Philippines (1,612) – 3%

6. India (1,604) – 19%

The latest Canadian IMG arrivals by main source country 2006-12

(practising):

Pakistan (+66%)

Egypt (+36%)

US (+31%)

South Africa (+25%)

India (+22%)

Decline = UK/ Scotland (-16%)

Issue 2 -

Pressure from Bilateral + Multilateral Agreements

Challenges:

Generically formed (often not field-specific)

Driven by national/ regional ‘goods and services’ agreements (trade)

Empirical base? Data on outcomes?

Variability in institutional calibre/ training

CASE STUDY:

East European IMGs seeking registration in UK and Ireland

Data on their integration into medical employment within 5 years:

Australia: 24% (compared to 83% of IMGs from UK/Ireland, 81% from South Africa, 66% from India,

59% from HK, 52% from NW Europe, 33% from the Philippines, 5% from China)

Canada: 8% (compared to 48% of IMGs from UK/Ireland, 81% from South Africa, 19% from India,

31% from HK, 36% from NW Europe, 3% from the Philippines, 4% from China)

Source: Based on 2001 Census data (all immigration categories)

2011 Census Evidence: Impact of Source Country/ Region on

IMGs’ Employment in Medicine in Australia (First 5 Years) –

Data on Eastern Europe?

2011 Census:

Overall: 57% of 2006-11 arrivals employed in medicine within 5 years

Most likely to practice: South Africa (83%), Malaysia (75%), UK/Ireland (74%), SE Europe (61%), India (61%), West Europe (59%), Singapore (56%)

Modest performers: Philippines (46%), South/ Central America (42%)

Poor outcomes: East Europe (27%), Vietnam (12%), China (8%), Indonesia (4%)

Unemployed or ‘Not in the labourforce’ within 5 years: China = 43%, Japan/ South Korea = 44%, Vietnam = 65%, Indonesia = 65%

Looming pressures – eg ASEAN (health sector focus)

Bilateral agreements – eg Japan-Indonesia (nursing case study)

Issue 3:

Impact of English Ability on IMG Registration (Australia)

Standard required: Set by relevant regulatory bodies

Data: Occupational English Test data (2005-2011)

Nurses (17%) Pharmacists (38%), Doctors (52%), Dentists (62%)

53%

20%

40% 38% 39%

46%

37%

43%

19%

47%

34%

28% 32%

34%

52%

17%

62%

32%

38% 40% 41%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

Ca

nd

ida

te p

as

s r

ate

(%

)

2005

2010

2011

Top Sources for International Medical Graduates

Accepted by Australia: 2006-11 Permanent Migrants

Medicine = 12,696 new IMGs

India: 2,625

Sri Lanka/ Bangladesh: 2,022

UK/ Ireland: 1,579

North Africa + Middle East: 1,194

Canada/ USA: 719

China: 705

Malaysia: 634

South Africa: 632

Other Africa: 479

Philippines: 473

Impact of English Ability – Regulatory Challenges

Pressure for ‘transparency + accountability’ as well as public safety:

Which instruments? What standards mandated?

Empirical basis of choice?

Exemptions? (Native speakers? International students?)

Length of test result validity?

Passes in all 4 tests at a single or multiple attempts?

Suitability for purpose? (eg clinical communication skills)

Extra tests for clinical communication? (when/ how)

Etc!

Impact on Native Speakers of Requirement to Pass All

English 4 Subtests at a Single Sitting: Nursing Data (2010)

100%

0%

36%

100%

8%

34% 33%

20% 20% 25%

58%

42%

24% 23% 22% 21% 20% 17% 17%

13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nu

rsin

g ca

nd

idat

e p

ass

rate

(%

)

Proportion of nursing candidates passing OET by select country of training, 2005 and 2010

2005

2010

Issue 4 -

Dominance of Temporary Resident IMGs

Challenges associated with temporary sponsored flows:

Hyper-mobility - Length of stay?

Immediacy of employment?

Clinical purpose/ location

Availability of supervision?

Willingness to invest in full registration

CASE STUDY: Fly-in Fly-out IMGs working in Saskatchewan or

Weipa or Afghanistan….

CASE STUDY: Sector demand (eg psychiatry ‘area of need’ in

Australia)

Case Study:

IMG Retention in Medicine in NZ (Within 5 Years)

Migration = ‘demographic survival’

1955-2004: 2.3 million migrants leads to net population gain of just

208,000 people

Dependence on migrant health professionals: Highest in the OECD

2005-09: 7,102 work permits issued to IMGs + 1,612 permanent

skilled migrants

2009: 323 new domestic graduates + 1,141 IMGs registered

Top sources: England, S Africa, Scotland, Australia, India, US, Sri

Lanka, Ireland, Germany + Iraq

Retention by 2008: Just 50% retained a year after initial registration +

31% for 3 years

Retention by source country + training system:

<50% from S Africa for 5 years

<30% from UK x 2 years

<30% from US/Canada IMGs x 1 year

Highest retention rate = Asia-trained IMGs (50% resident @7 years)

2012: 41% of medical workforce = IMGs (38% in 2007)

Issue 5 -

Pressure for Partial Licensure for IMGs

• Limited scope of practice – Restricts migrant health professionals to

defined functions excluding areas of practice in which they have limited

experience and/or more senior, unsupervised areas of responsibility

(eg within medicine mandating a requirement for supervised clinical

practice, or in pharmacy extended periods of supervised ‘adaptation’).

• Conditional registration – Allows applicants deemed to have near-

sufficient skills or education to be licensed in the host country on a

limited or conditional basis to undertake training (for example through

completion of host country bridging programs, internships, or

examinations).

• Restricted practice time frames – Provides defined periods of

licensure that cater, for example, to transnational corporation

employees (for example which provide health workers to remote mining

companies

OECD (2008) -

Partial Licensure for IMGs

Global examples of conditional licensing for IMGs include:

• UK: Securing a pass grade on the Professional and Linguistic

Assessments Board (PLAB) exam prior to a year of supervised practice

• Finland: Supervised service in a hospital, then a health center, then

private practice

• US: Completion of a residency (highly competitive to secure places)

• Canada: Repetition of two to six years of university training, depending

on the credits awarded for previous study

• Multiple countries: Public hospital practice under variable levels of

supervision

Australia 2008+: Alternative Registration Pathways for IMGs –

Recruitment Impact of the Competent Authority Pathway

Specialists

? X

Fast

Me

diu

m

Slo

w

Australian Medical Council Research Evidence:

Informing Pathways to Registration

Requirement Fast- Track

Medium-Track

Full- Track

Specialist Track

Name Competent Authority Pathway

Work-Based Assessment Pathway

Australian Medical Council Pathway

Run by Royal Colleges

English Test Pass

Yes Yes Yes Yes

MCQ Exam Pass

No Yes Yes

Clinical Exam Pass

No No Yes

12 Months Supervised Practice

Yes Yes Yes

Issue 6 -

Catering to the Study-Migration Pathway

Challenges:

The case for testing exemptions?

1. Returning citizens

2. Country of qualification

3. Institution of qualification

Empirical evidence for decision-making?

Location of study (institutional calibre)

CASE STUDY: Returning Canadian students qualified in Australia

or Ireland or UK or Poland or India (scale of

demand!)

OECD Policy:

International Higher Education Students as a Priority

Talent Resource

Top 12 Global Destination Countries (2007-2008)

International Students Enrolled in Higher/ Vocational Education

1. US 623,805 (2008)

2. Australia 389,373 (2008)

3. UK 389,330 (2008)

4. France 260,596 (2008)

5. Germany 246,369 (2007)

6. China 223,499 (2008)

7. Japan 123,829 (2008)

8. Canada 113,996 (2007)

9. Singapore 86,000 (2007)

10. Malaysia 72,000 (2008)

11. South Korea 63,952 (2008)

12. New Zealand 39,942 (2007)

Source: Compiled from data provided in International Student Mobility: Status Report 2009, V Lasanowski, The Observatory on Borderless Higher Education, UK, June 2009

Potential Value of the Study-Migration Pathway:

‘Designer Immigrants’?

Attributes: Young

Self-funded education

Length of future productivity

Host country language skills

Domestic qualifications

Acculturation

Australian case study:

1999: Immediate eligibility to migrate (supported by bonus points)

2005: 66% of Indian students and 38% of Chinese students

migrate on course completion

2007-11: 78% of international medical students plan to migrate

2011: 99% employed full-time year after graduation; wage parity to

Australians in PGY1

Issue: Future access to internship places? (Pre-requisite for PR

status)

Employer Place of Selection –

Facilitating Two-Step Migration (2011-12)

Former International Students: Full-Time Employment Rates 6

Months After Completing Australian Degrees by Field Compared to

Domestic Students (2007-11)

Qualification Field Australian Graduates

(Sample = 371,000)

International Students

(Sample = 79,000)

Accounting 83% 35%

Business 76% 40%

IT 78% 42%

Engineering 86% 44%

Medicine 100% 99%

Dentistry 94% 96%

Pharmacy 98% 96%

Physiotherapy 94% 67%

Nursing 92% 71%

Issue 7 -

Changing Regulation Strategies in Other Fields

Engineering – Washington Accord: Member countries = Select number

Regulatory body capacity-development = Prior to membership (eg Malaysia, China)

Recognition = Select institution of training

Control = Destination country regulatory body

Accounting – ACCA (Association of Chartered Certified Accountants):

Status = Global industry qualification

Providers = Licensed

Training = Upgrades for 1+ planned destination countries

Caters to = Hypermobile professionals

Mining/ Geoscience – CRIRSCO (Committee for Mineral Reserves International Reporting

Standards):

Status = Recognition of ‘global competent persons’

Pre-requisite 1 = Nationally accredited by home country institution

Pre-requisite 2 = Nominated by 3 CRIRSCO members

Pre-requisite 3 = Minimum of 5 years approved professional experience in defined field

Then globally approved to assess mineral deposits for listing on world stock exchanges

The Challenge:

Mismatch Between Regulatory Systems and 21st Century Mobility

Patterns

Stakeholder pressure:

• Employers seek more agile and responsive accreditation

systems, matched to contemporary migration modes and sector

needs.

• Governments urge regulatory bodies to change, in order to

maximize workforce efficiency and social justice outcomes.

• Globally mobile professionals advocate to be able to transfer

and use their skills, including when relocating on a temporary

basis.

• Regulatory bodies are under growing pressure to adapt, spurred

by the scale of migration in regulated fields, the development of

bilateral and multilateral agreements, rapid growth in temporary

flows, expansion of the study-migration pathway, and national or

regional reform agendas