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Migration of Nursing and Midwifery
Workforce from Kerala
Study Findings
Tomas Zapata
HRH Regional Advisor
WHO-SEAR
Outline
• Production of nurse and midwives
• Stock of nurse and midwives
• Migration of nurse and midwives from Kerala
• Conclusions & recommendations
Production
Total in 2016: 287
- 11% public – 89%
privateSource: Indian Nursing Council/KNMC
Number of training institutions in Kerala (2005-2016)
91
219204
12
126 133
15
20 20
0
50
100
150
200
250
2005 2012 2016
General Nursing andMidwifery
BSc (Nursing)
Auxiliary Nursing andMidwifery
Production
• Number of
college seats
in 2016:
17,600
(91% private)
• Growth in
seats faster
in public
colleges
seen from
2012-16
(marginal)
Source: Indian Nursing Council
Production capacity (number of seats, maximum production capacity)
0
2000
4000
6000
8000
ANM GNM BSc(Nursing)
MSc(Nursing)
PB BSc(Nursing)
PBDiploma
2012 2013 2014 2015 2016
Source: Indian Nursing Council
Production
• Number of
college seats
in 2016:
17,600
(91% private)
• Growth in
seats faster
in public
colleges
seen from
2012-16
(marginal)
Source: Indian Nursing Council
Production capacity (number of seats, maximum production capacity)
0
2000
4000
6000
8000
ANM GNM BSc(Nursing)
MSc(Nursing)
PB BSc(Nursing)
PBDiploma
2012 2013 2014 2015 2016
Source: Indian Nursing Council
Number of nurse registrations with KNMC (2009-2016)
0
1000
2000
3000
4000
5000
6000
2009 2010 2011 2012 2013 2014 2015 2016
General Nursing andMidwifery
BSc (Nursing)
Auxiliary Nursing andMidwifery
New registrations of
nurses and midwives
in 2016: 9,766Source: Kerala Nurses and Midwives Council
Production
Stock of Nurses & Midwives
0 10 20 305 15 25Density per 10000 population
KeralaDelhi
HaryanaMaharashtra
GujaratAndaman & Nicobar Islands
UttarakhandMizoram
PunjabTamil Nadu
LakshadweepNagaland
ChattisgarhKarnataka
Jammu & KashmirIndia
SikkimAndhra Pradesh
ManipurUttar Pradesh
GoaMeghalaya
West BengalMadhya Pradesh
Arunachal PradeshTripura
RajasthanOrissa
JharkhandAssam
Himachal PradeshBihar
Allopathic Doctors Nurses and Midwives
All
Source: Rao, KD, Shahrawat, R., & Bhatnagar, A. (2016). Estimates based on 2012 NSSO
Stock of Nurses & Midwives
0 10 20 305 15 25Density per 10000 population
KeralaDelhi
HaryanaMaharashtra
GujaratAndaman & Nicobar Islands
UttarakhandMizoram
PunjabTamil Nadu
LakshadweepNagaland
ChattisgarhKarnataka
Jammu & KashmirIndia
SikkimAndhra Pradesh
ManipurUttar Pradesh
GoaMeghalaya
West BengalMadhya Pradesh
Arunachal PradeshTripura
RajasthanOrissa
JharkhandAssam
Himachal PradeshBihar
Allopathic Doctors Nurses and Midwives
All
Source: Rao, KD, Shahrawat, R., & Bhatnagar, A. (2016). Estimates based on 2012 NSSO
India: 3.1 nurses
and midwives /10,000
(NSSO 2012)
3.1
Stock of Nurses & Midwives
0 10 20 305 15 25Density per 10000 population
KeralaDelhi
HaryanaMaharashtra
GujaratAndaman & Nicobar Islands
UttarakhandMizoram
PunjabTamil Nadu
LakshadweepNagaland
ChattisgarhKarnataka
Jammu & KashmirIndia
SikkimAndhra Pradesh
ManipurUttar Pradesh
GoaMeghalaya
West BengalMadhya Pradesh
Arunachal PradeshTripura
RajasthanOrissa
JharkhandAssam
Himachal PradeshBihar
Allopathic Doctors Nurses and Midwives
All
Source: Rao, KD, Shahrawat, R., & Bhatnagar, A. (2016). Estimates based on 2012 NSSO
3.1
18.5 61,619 nurses in Kerala
India: 3.1 nurses
and midwives /10,000
(NSSO 2012)
Stock of Nurses & Midwives
0 10 20 305 15 25Density per 10000 population
KeralaDelhi
HaryanaMaharashtra
GujaratAndaman & Nicobar Islands
UttarakhandMizoram
PunjabTamil Nadu
LakshadweepNagaland
ChattisgarhKarnataka
Jammu & KashmirIndia
SikkimAndhra Pradesh
ManipurUttar Pradesh
GoaMeghalaya
West BengalMadhya Pradesh
Arunachal PradeshTripura
RajasthanOrissa
JharkhandAssam
Himachal PradeshBihar
Allopathic Doctors Nurses and Midwives
All
Source: Rao, KD, Shahrawat, R., & Bhatnagar, A. (2016). Estimates based on 2012 NSSO
18.53.1 6x
India: 3.1 nurses
and midwives /10,000
(NSSO 2012)
61,619 nurses in Kerala
Position YearRequired
[R]
Sanctioned
[S]
In
position
[P]
Vacant
[S–P]
Shortfall
[R–P]
Health workers
(female)/ANMs at
subcentres and PHCs
2007 6 003 5 670 5 634 36 369
2012b 5 384 4 232 4 173 59 1 211
2016 5 399 7 929 7 950 * *
Health assistants
(female)/LHVs at PHCs
2007 909 830 740 90 169
2012 NA NA NA NA NA
2016 824 13 13 0 811
Nursing staff at PHCs
and CHCs
2007 1 658 2 811 3 064 * *
2012 2 328 2 099 2 014 85 314
2016 2 399 3 610 3 969 * *
Source: Bulletin on Rural Health Statistics 2016, MoHFW
Number of vacancies of nurses working in rural health facilities in Kerala (2016)
Stock of Nurses & Midwives
Position YearRequired
[R]
Sanctioned
[S]
In
position
[P]
Vacant
[S–P]
Shortfall
[R–P]
Health workers
(female)/ANMs at
subcentres and PHCs
2007 6 003 5 670 5 634 36 369
2012b 5 384 4 232 4 173 59 1 211
2016 5 399 7 929 7 950 * *
Health assistants
(female)/LHVs at PHCs
2007 909 830 740 90 169
2012 NA NA NA NA NA
2016 824 13 13 0 811
Nursing staff at PHCs
and CHCs
2007 1 658 2 811 3 064 * *
2012 2 328 2 099 2 014 85 314
2016 2 399 3 610 3 969 * *
Source: Bulletin on Rural Health Statistics 2016, MoHFW
Number of vacancies of nurses working in rural health facilities in Kerala (2016)
Stock of Nurses & Midwives
Position YearRequired
[R]
Sanctioned
[S]
In
position
[P]
Vacant
[S–P]
Shortfall
[R–P]
Health workers
(female)/ANMs at
subcentres and PHCs
2007 6 003 5 670 5 634 36 369
2012b 5 384 4 232 4 173 59 1 211
2016 5 399 7 929 7 950 * *
Health assistants
(female)/LHVs at PHCs
2007 909 830 740 90 169
2012 NA NA NA NA NA
2016 824 13 13 0 811
Nursing staff at PHCs
and CHCs
2007 1 658 2 811 3 064 * *
2012 2 328 2 099 2 014 85 314
2016 2 399 3 610 3 969 * *
Source: Bulletin on Rural Health Statistics 2016, MoHFW
Number of vacancies of nurses working in rural health facilities in Kerala (2016)
Vacancies in private sector???
Overseas migration from Kerala
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
2011 2013 2016
Stock of Nurses andNurse Assistants
Nurse and NurseAssistant Migrants
Overseas migration from Kerala
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
2011 2013 2016
Stock of Nurses andNurse Assistants
Nurse and NurseAssistant Migrants31%
Overseas migration from Kerala
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
2011 2013 2016
Stock of Nurses andNurse Assistants
Nurse and NurseAssistant Migrants31%
Emigration rate: 32.8% (2011)23.2% (2016)
Source: Kerala Migration Survey 2016, Center for Development Studies
Percentage share of emigrant nurses and nurse assistants in major destination countries
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
Migration within India from Kerala
Karnataka
41%
Delhi
31%
Tamil
Nadu
14%
Uttar Pradesh
6%
West Bengal
2%
Gujarat
1%Rajasthan
1%
Madhya Pradesh
1% Chhattisgarh
1%
Andhra Pradesh
1%
Others*
1%
0
1000
2000
3000
4000
0
500
1000
1500
2012 2013 2014 2015 2016Total Delhi Nursing Council
Karnataka Nursing Council Tamil Nadu Nursing Council
Uttar Pradesh Nursing Council
Trends in migration of nurses from Kerala to other Indian States
Source: Data on issuance of certificates of no objection, Kerala Nurses and Midwives Council
Conclusions & Recommendations• Slowing down of overseas migration of nurses, high production capacity, low
vacancy rates & low internal migration: moving towards an oversupply of nurses
• Reasons for declining migration of nurses from Kerala to foreign countries ought
to be investigated further. Perceived low quality/skills?, soft skills, language? How
to address them
• Oversupply contributes to low salaries in private sector + wage differential between
Kerala and abroad could translate into demands for salary increases. Recent nurse
strike in Kerala reflective of this
- Ensuring enhanced working conditions, salaries, enforcement of minimum
wage in private sector
- Govt could create conditions for enhancing role of nurses in health system –
e.g. licensing nurse practitioners, creating prescription formulary for nurses
• Sign MoU between Kerala and destination countries, promote internal migration
• Methods
Spare slides
Migration from Kerala
YearStock of Nurses and Nurse
Assistants
Nurse and Nurse
Assistant Migrants
Net Emigration Rate
(%)*
2011 61,613 30,038 32.8%
2013 63,224 28,138 30.8%
2016 68,161 20,622 23.2%
*Calculated as: [Migrant nurses and nurse assistants /(Resident nurses and nurse assistants + Migrant nurses and nurse assistants)] * 100
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
Migration from Kerala
YearStock of Nurses and Nurse
Assistants
Nurse and Nurse
Assistant Migrants
Net Emigration Rate
(%)*
2011 61,613 30,038 32.8%
2013 63,224 28,138 30.8%
2016 68,161 20,622 23.2%
*Calculated as: [Migrant nurses and nurse assistants /(Resident nurses and nurse assistants + Migrant nurses and nurse assistants)] * 100
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
31%
Migration from Kerala
YearStock of Nurses and Nurse
Assistants
Nurse and Nurse
Assistant Migrants
Net Emigration Rate
(%)*
2011 61,613 30,038 32.8%
2013 63,224 28,138 30.8%
2016 68,161 20,622 23.2%
*Calculated as: [Migrant nurses and nurse assistants /(Resident nurses and nurse assistants + Migrant nurses and nurse assistants)] * 100
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
9.6%
Migration from Kerala
YearStock of Nurses and Nurse
Assistants
Nurse and Nurse
Assistant Migrants
Net Emigration Rate
(%)*
2011 61,613 30,038 32.8%
2013 63,224 28,138 30.8%
2016 68,161 20,622 23.2%
*Calculated as: [Migrant nurses and nurse assistants /(Resident nurses and nurse assistants + Migrant nurses and nurse assistants)] * 100
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
• Fall in net emigration rate of nurses and nursing assistants
• Over 90% of emigrant nurses employed in private sector before migration
• Nurses migrated for an average of 5-6.5 years
Number of nurse registrations with KNMC (2009-2016)
2152
0
1000
2000
3000
4000
5000
6000
2009 2010 2011 2012 2013 2014 2015 2016
General Nursing andMidwifery
BSc (Nursing)
Auxiliary Nursing andMidwifery
7210 Number of seats in 2013
Source: Kerala Nurses and Midwives Council
Number of nurse registrations with KNMC (2009-2016)
2152
0
1000
2000
3000
4000
5000
6000
2009 2010 2011 2012 2013 2014 2015 2016
General Nursing andMidwifery
BSc (Nursing)
Auxiliary Nursing andMidwifery
7210 Number of seats in 2013
70% gap
Source: Kerala Nurses and Midwives Council
Source: Kerala Migration Survey, 2011, 2013 and 2016; Analysis by Oxford Policy Management and CDS, Thiruvananthapuram
22%
15%12%
10%
6% 6% 6% 4% 3% 3% 3%
%
10%
20%
30%
40%
Saudi
Arabia*
UAE Kuwait UK USA Qatar** Canada Others Germany Maldives Australia
2011 2013
Percentage share of emigrant nurses and nurse assistants in major destination countries(2011, 2013, 2016)
Factors influencing Migration Patterns
‘Push’ Factors ‘Pull’ Factors
• Low remuneration
• Difficult working conditions, including:
- Low patient-nurse ratio, high workload
- Limited training and education opportunities
• Unclear career pathways
• Shortage of nursing personnel in destination countries
• Ageing population
• Higher salaries, personal and professional
opportunities
• Migration to other Indian states: Employment in
major cities and leading hospital facilities (public/pvt)
• Drop in migration from Kerala to Gulf countries due to recent structural changes in policies:
- Nurses migrating to ECR (emigration checked required) countries require emigration
clearance
- Foreign employers to register with eMigrate system
- Recruitment only via state-mandated agencies – ODEPC, NORKA-ROOTS, TNAI
- Reduction of quality of trained nurses (English, soft skills)??
- Increased requirements in destination countries
• Interviews with nursing students indicate preference for permanent, full-time position in
Kerala public health system over migration (particularly to Gulf countries)
Conclusions & Recommendations
• Sign MoU between Kerala and destination countries
• Estimates of production, stock, and migration foreground extent of divergence
between data sources:
- Nodal institution in Kerala should track and compile information on
migrant health workers, including nurses – NORKA-ROOTS undertaking
steps on this
- Implement live register for nurses, interoperable with other info systems to
provide strategic information (including migration data)
Migration of Nurses from India
• Steady declines in annual inflow of Indian nurses to OECD countries since 2005
• US and UK see declining share of emigrant nurses, while Canada and Australia have
registered rises (absolute numbers much smaller than Gulf)
• Shifts in preference for destination countries may partly be result of destinations’ migration
policies – more family-friendly policies, longer term residency prospects
0
2500
5000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Canada United Kingdom United States New Zealand Italy
Source: Health Workforce Migration – OECD