This appendix is intended to complement the issues covered in Chapter 6 about health workforce supply in Australia and provide further detail and some international context to the analysis of current health workforce supply initiatives.
Australia both imports and exports health professionals, as these often highly trained personnel move to further their education, knowledge and specialty skills in advanced health care settings. Australian graduates will travel to the United Kingdom, the United States of America, Canada and New Zealand to further their training and return to Australia, some of course do not return.
Overall Australia is a net importer of health professionals, particularly medical professionals, and competes against most other Organisation for Economic Cooperation and Development (OECD) countries for these keenly sought after personnel.240
Overseas trained doctors (OTDs) (also known as international medical graduates (IMGs)) are doctors who obtained their primary qualification overseas. OTDs provide a significant proportion of the Australian medical workforce, particularly in those areas where it is difficult to attract Australian trained doctors. Issues relating to the employment of OTDs within the Australian health workforce are discussed in detail in Chapter 6.
Australia has the stated aim of becoming self-sufficient in its health workforce by 2025, but as stated in earlier chapters all available evidence is that the increase in domestic graduates is unlikely to provide sufficient numbers to meet this aim. Importing health workers will continue to be a strategy for the foreseeable future to ensure Australians have access to health care services/providers.
Based on the place of basic qualification, approximately 25% of the medical workforce in Australia are OTDs.241 OTDs who have applied to work in Australia have received initial medical training in 120 countries, and specialist qualifications from 91 different countries.242 They enter Australia under a range of employment arrangements and visa categories. In 2009-10, 46%, of general practitioners in rural and remote areas were OTDs compared to 27% in 2000-01.
State and territory governments are the major employers of health professionals, as well as providing training opportunities, particularly in public hospitals. States and territories are able to sponsor OTDs on long stay visa subclass 457, as are private medical practices and/or medical recruiting companies. The Australian Government has an expectation that those who recruit OTDs to work in Australia abide by the appropriate Code(s) of Practice, relating to recruitment of international health personnel.
It should also be noted that health professionals who obtained their initial qualifications overseas must still meet the requirements of the National Registration and Accreditation Scheme (NRAS) to practise in Australia. These standards are higher than the standards for immigration purposes, particularly the English language standards.
Many stakeholders in the Australian medical/health sector believe that Australia will be more dependent on OTDs and other overseas trained health professionals (particularly nurses) in the future in the light of an ageing ‘baby-boom-generation’ suggesting that many current health professionals will soon retire.243
The recruitment of international health personnel is governed by a range of international agreements and codes of practice (as described at the conclusion of this appendix) which adds some complexity to the arguments around substituting the domestic workforce with international health professionals.
These issues around projected medical workforce shortages do not affect Australia alone; the shortfall in the medical workforce can be seen worldwide with a subsequent overall migration of medical practitioners and specialists. Australia competes for medical specialists in a highly competitive market with other jurisdictions (e.g. Canada, United States, Scandinavia, Central Europe) with most conducting active recruitment and integration programs.
Trends in international health professional entry to Australia
OTD entry to Australia
OTDs enter Australia to work as permanent residents or on temporary work visas.
Data from the 2006 Census (Survey of Population and Housing)244 shows that there were 3,586 generalist medical practitioners and 1,566 specialists who had recently arrived in Australia.
- In 2006, India was the most common country of birth for recently arrived generalist and specialist medical practitioners, with 19.2% and 23.3% respectively born there.
- The proportion of recently arrived generalist medical specialists who were born in India increased from 8.3% in 1986 to 19.2% in 2006, whilst the proportion of recently arrived specialist medical practitioners who were born in India rose from 3.8% to 23.3%.
- The proportion of recently arrived medical practitioners who were born in England and New Zealand decreased over this time.
The following charts provide some general information on the origin of OTDs moving to Australia:
Figure vi.1: Arrivals by birthplaceD
Source: Australian Bureau of Statistics, Census 2006
Figure vi.2 shows that, in 2011-12, 34% of visa applications for medical practitioners came from the United Kingdom, followed by India and Malaysia.
Figure vi.2: Country of origin of 457 and 442245 visa applications for medical practitioners, 2011-12D
Source: Department of Immigration and Citizenship administrative data.
Figure vi.4 below shows the number of temporary visas granted to medical practitioners from 2006-07 to 2011-12.
Figure vi.4: Trends in OTD visa types 2006-07 to 2011-12246D
Source: Department of Immigration and Citizenship administrative data.
Trends in the immigration of internationally trained nurses
In Australia international recruitment activities are conducted through the Commonwealth funded International Recruitment Strategy (IRS) and the International Recruitment Program (managed by HWA), as discussed in Chapter 6. In addition, states and territories actively seek to recruit health professionals (particularly nurses) predominately to regional, rural and remote regions. Many jurisdictions have long standing relationships with specific countries.
Additionally, a number of projects are managed by AusAid aimed at improving nurse education in the Pacific region, predominately in the Philippines. The Australian Government holds bi-annual meetings at Ministerial level with the Philippines and this country has sought to investigate the possibilities of exporting more health professionals to Australia.
The data for nurses presented in the figure below mirrors the trends in immigration flows shown above for the international medical workforce and also shows a recent increase in numbers in 2011-12.
Figure vi.5: Trends in Visa 457 (long stay) issued to nurses and midwives 2005-06 to 2011-12D
Source: Department of Immigration and Citizenship data released in August 2012
Note that the Commonwealth is not able to influence where internationally trained nurses work, as there is no distribution lever, such as s. 19AB of the Health Insurance Act 1973, relevant to nurses.
Allied Health Professionals – Immigration trends
There is limited information on the immigration of allied health professionals. National data sets are immature for this group of health professionals. For those allied health professions subject to NRAS robust data sets will be developed over time. These data issues are discussed in previous chapters of this review.
Recent changes in immigration arrangements
The broad environment for migration to Australia has a significant impact on the arrangements for international health workers seeking to move to this country.
The Australian Government, via the Department of Immigration and Citizenship (DIAC), seeks input from other Australia Government departments, relevant industry and education sectors and Skills Australia to develop a priority skills occupation list. Potential migrants who have skills that are perceived to be in demand in Australia, can earn additional points towards an entry visa. Doctors, nurses and many allied health professions are included on this list.
However, over recent years (2009-10 and 2010-11 budgets) DIAC has developed and implemented a new visa system, which became fully operational during 2012. This process involves reducing visa subclasses by up to 50%. Of relevance to international health professionals is that subclasses 422 and 442 have been removed. Health professionals who may have been eligible for these visas will now need to meet the conditions of other visa subclasses, and will now have to apply under subclass 457. This will alter the pattern of entry and therefore close monitoring of trend data in the next few years will be important.
The new system replaces the visa application process for many groups, particularly those immigrating under skilled migration and long stay visa classes (such as visa subclass 457, which the majority of international health professionals use). This process was piloted /trialled in July/August 2012 and the results are being assessed by DIAC.
Revised immigration processes may impact on the health workforce trend data, as only those people who meet all immigration and employment requirements will be able to enter and work in Australia. Careful monitoring of the data related to internationally trained health professional in future years will be required to assess the impact of these changes on Australia’s health workforce.
Codes of conduct or practice on international recruitment of health personnel
Australia is a signatory to a number of voluntary codes of practice related to the recruitment of internationally trained health professionals. These codes include:
- The World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel (2010)
- The Commonwealth Code of Practice for the International Recruitment of Health Workers (initially signed in 2003 and updated in 2005-06)
- The Pacific Code of Practice for Recruitment of Health Workers (2007 and last updated in 2010).
Purpose of these codes
All these codes are intended to provide guidelines for the international recruitment of health workers in a manner that takes into account the potential impact of such recruitment on services in the source country.
The codes are intended to discourage the targeted recruitment of health workers from countries which are themselves experiencing shortages. Additionally, the codes seek to safeguard the rights of recruits, and the conditions relating to their profession in the recruiting countries.
Status of these codes
The Commonwealth and Pacific codes are not legal documents. Within the context of Commonwealth principles of cooperation and consensus, it is hoped that governments will subscribe to the codes. The codes apply the principles of transparency, fairness and mutuality of benefits as these relate to relations among Commonwealth countries, and between recruits and recruiters.
The WHO Global Code of Practice on the International Recruitment of Health Personnelwas adopted by the World Health Assembly (WHA) in May 2010. This code is voluntary. The Australian Government supported the global code of practice that was endorsed by the WHA in May 2010.
The OECD and the WHO jointly developed the WHO Global Code of Practice including holding joint meetings and working groups. There is an expectation that member states/countries will abide by and implement the WHO Code.
240 House of Representatives Standing Committee on Health and Ageing, Lost in the Labyrinth: Report on the inquiry into registration processes and support for overseas trained doctors, Canberra August 2012
241 AIHW Medical Labour Force 2009
242 Geffen L, editor. Assuring medical standards: the Australian Medical Council 1985–2010. Canberra, ACT: Australian Medical Council, 2010
243 House of Representatives Standing Committee on Health and Ageing, Lost in the Labyrinth: Report on the inquiry into registration processes and support for overseas trained doctors, Canberra August 2012
244 Equivalent data under the 2011 Census was not available at the time of this report’s production.
245 Visa subclass 457 – Business (long stay). Since 24 November 2012 the 457 visa has been renamed as the temporary work (skilled) visa; Visa subclass 442 – Occupational trainee visa.
246 Visa subclass 422 was the medical practitioner (temporary) visa. This visa class closed on 1 July 2010.