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Can We Care for Aging Persons without Worsening Global Inequities? The Case of Long-Term Care Worker Migration from the Anglophone Caribbean

Can We Care for Aging Persons without Worsening Global Inequities? The Case of Long-Term Care... Abstract The international migration of health workers, including long-term care workers (LCWs) for aging populations, contributes to a shortage of these workers in many parts of the world. In the Anglophone Caribbean, LCW shortages and the migration of nurses to take on LCW positions abroad threaten the health of local populations and widen global inequities in health. Many responses have been proposed to address the international migration of health workers generally, including making it more difficult for these workers to emigrate and increasing and improving local employment opportunities. In this article, we suggest an additional means of ethically reducing health worker migration, targeting the Anglophone Caribbean specifically. Countries in this region can take advantage of their warmer climate and well-trained work force to encourage aging populations in the global north to emigrate temporarily or permanently through international retirement migration. As a result, countries in the Anglophone Caribbean can not only decrease the international migration of trained health workers through the provision of well-paying, local jobs, but potentially reverse this flow by drawing on the international diaspora of their workers. International retirement migration, if carefully managed, can reduce global inequities in health while treating both retirees and LCWs ethically. In wealthy countries such as Canada and the USA, a shift in the culture of care away from institutionalization and toward home and community-based care, along with demographic shifts toward older populations, has resulted in a dramatic increase in demand for long-term care workers (LCWs) such as homecare nurses and care aides (Eckenwiler, 2012). As a result, long-term care jobs, such as Home Health Aides and Personal Care Aides, are projected to be the third and fourth fastest-growing occupations in the USA between 2008 and 2018 (Paraprofessional Health Institute, 2011), respectively. Work performed by LCWs often centers around core activities of daily living, such as bathing and eating, and therefore is likely to influence not only a patient’s quality of care but quality of life. LCWs have more contact with care recipients than physicians, heavily influencing quality of care (Stone and Harahan, 2010). As a result, insufficient numbers of LCWs will drastically and negatively impact quality of life for aging persons as demand for LCWs increases. LCWs are often poorly paid in high-income countries and face poor working conditions, including poor occupational and safety standards and physically demanding job requirements. As a result, employers often find it difficult to staff these positions from the existing supply of resident workers (Browne and Braun, 2008). For this reason, long-term caregiving positions are sometimes filled by migrant workers who are attracted to these positions by higher wages and better career opportunities than are available in their home countries (Eckenwiler, 2012). Flows of LCWs are influenced by the impacts of colonization, with factors such as language fluency, nursing culture and training culture all contributing to migration patterns (Redfoot and Houser, 2008). Other factors, such as geographic proximity and prioritized work visa initiatives, play an important role in influencing migratory flows. In Europe, nations in Central and Western Europe increasingly source nurses from Eastern Europe (Redfoot and Houser, 2008). Intra-regional and stepwise movement of LCWs occurs within Africa as well, such as from the Democratic Republic of the Congo to Kenya and from Kenya to South Africa, Namibia and Botswana. Many African nations, such as South Africa, are both destination and source countries for LCWs (Connell et al., 2007). The active recruitment of LCWs (where recruiters take positive steps to encourage and facilitate migration) also influences migration patterns. Lofters (2012) suggests active recruitment from wealthy countries is a major driving force for Anglophone Caribbean nurse migration, stating that in 2006, 41 per cent of migrant nurses in Britain reported migrating there because of recruitment. Indeed, the growing demand for LCWs has contributed to the rapid growth of for-profit international recruitment industry, related to recruitment, testing, credentialing and immigration (Eckenwiler, 2012). We contend that transnational patterns of LCW migration have significant implications for global health equity for LCW source countries, LCW destination countries and LCWs themselves. By ‘global health equity’, we refer to differences, from the local to the international scale, in access to the resources necessary to maintain a reasonable standard of health and well-being that are not naturally occurring and are unfair or unjust. In this article, we identify these inequities and policies that have been advocated for reducing them, focusing on LCW migration from the Caribbean. We then suggest that Anglophone Caribbean nations in particular should take a lesson from international health travel (or ‘medical tourism’) and consider promoting international retirement migration (IRM) as an additional tool for more equitably addressing the global demand for LCWs. The Caribbean Context The Anglophone Caribbean region has historically struggled to retain health workers that serve as eldercare workers abroad. This is true particularly in the English-speaking Caribbean where health workers’ language skills create employment opportunities in Canada, the USA and the UK, among other countries. An examination of the outflow of nurses from the Caribbean is illustrative of this problem, though LCWs are not drawn exclusively from the nursing ranks nor do Caribbean nurses migrate only to take on LCW positions. Data on nurse migration is much better than for most other categories of health workers in the Caribbean, however, and examining these data gives a general sense of the scope of the problem. Migration out of the Caribbean region is the main cause of nurse attrition within that region (World Bank, 2009). In 2009, it was estimated that there were 21,000 Caribbean-trained nurses working in North America (15,500 USA, 750 Canada) and the UK (4750) compared with only 7800 remaining in the Caribbean—a shocking ratio of three times the number of Caribbean-trained nurses working outside of the Caribbean compared to within the Caribbean—though the pace of this migration was slowing at the time (World Bank, 2009). In 2007, it was estimated that the percentage of nurses leaving for Organization for Economic Co-operation and Development (OECD) countries was above 70 per cent for most of the Caribbean, including 88 per cent for Jamaica and 78 per cent for Barbados (Dumont and Zurn, 2007). This migration of nurses and other health workers has led to a health worker shortage throughout the Caribbean. The World Bank (2009) found 2700 nursing vacancies within the region. Vacancy rates vary by country, with nursing vacancy rates of 20.6 per cent in Barbados, 58.4 per cent in Jamaica, 26 per cent in St. Kitts and 53.3 per cent in Trinidad and Tobago and a regional average of 35 per cent (Hosein and Thomas, 2007). Jamaica has been calculated to lose 8 per cent of its nurses and 20 per cent of its specialist nurses to international migration each year (Wyss, 2004). Barbados saw numbers of registered nurses fall from 701 in 2002 to 551 in 2004 (Sealy, 2011). Nurses from the Caribbean are motivated to emigrate due to low pay at home, poor working conditions in local private and public facilities, limited career advancement opportunities, limited employment opportunities in their home countries, lack of job security and occupational risks. By comparison, countries like the USA, Canada and UK offer higher nominal and real incomes, a better standard of living, better working conditions, better educational and training opportunities and the opportunity to improve the lives of family members through remittances (Caribbean Commission on Health and Development, 2006; Sealy, 2011). While many Caribbean-trained nurses go abroad to serve in nursing positions, others will accept LCW positions because their nursing credentials are not accepted in their destination country or to gain a foothold in a new country with the aim of eventually gaining employment in a nursing position. Thus, LCW positions serve as an additional draw for trained nurses in the Caribbean to migrate abroad (Eckenwiler, 2012). The educational capacity in the region is insufficient to replace these workers, and this problem is exacerbated by the loss of the best trained and most experienced workers, some of whom staff these educational facilities, resulting in a reduced capacity to train new workers (Salmon et al., 2007). Top graduates of nursing training programs were also seen to be most likely to migrate abroad, undermining the development of a new generation of educators and leaders in the field (World Bank, 2009). Losses of health workers in one part of the Caribbean can worsen shortfalls in other parts of the region as well. Countries like Jamaica have turned to other, less affluent Caribbean countries to meet their domestic health worker shortfall, spreading the effects of health worker migration (Salmon et al., 2007). The population in the Caribbean is aging, creating increased regional demand for eldercare that create additional demands on already insufficient LCW resources Emigration by the children of aging Caribbeans reduces the number of informal family caregivers available and creates further demand for professional caregivers (Eckenwiler, 2012). As a result, demand for health workers, including LCWs, will only increase in the Caribbean, worsening the impact of shortfalls in the supply of these workers. Global Health Equity Impacts The transnational migration of LCWs is motivated by the prospect of new and better employment opportunities for these workers and, often, the prospect of helping families left behind by sending them remittances. In Jamaica, remittances account for nearly 20 per cent of national gross domestic product (Lofters, 2012). However, this pattern of migration also creates significant negative consequences for a range of groups, including members of the migrants’ home countries, members of the migrants’ destination countries and for the migrants themselves and their families. The primary equity concern with LCW out migration is that it further worsens existing shortages of these workers in their home countries. As discussed above, the Anglophone Caribbean region and many other low- to middle-income regions have had difficulty training and retaining adequate numbers of these workers, particularly skilled health workers such as nurses. Due to the loss of these workers, some source countries have a more difficult time meeting their own eldercare needs (Salmon et al., 2007; Eckenwiler, 2009). This pattern of migration leads to an unjust redistribution of resources from less economically developed countries to richer nations. Destination countries lose out on the investments they have placed in training these workers while receiving little or nothing in return (Jones et al., 2009). Costs of nurse migration to the Caribbean Community and Common Market region were estimated at US$16 million in 2001 (Thomas et al., 2005). In Jamaica, many nursing students enter training already with firm plans to migrate, meaning that this country will receive nothing in return for its investment in training these workers (WHO, 2010). LCWs who migrate abroad for work often do so to obtain higher wages and to send some portion of these wages home to their families as remittances. However, remittances from workers who migrate abroad remain insignificant among the poorest and most marginalized members of these communities (Kalipeni et al., 2012) and the multiple adverse social and economic costs of migration to national economies and health systems are generally thought not to be offset by the flow of remittances (Lofters, 2012). LCW migration worsens problems with retaining adequate numbers of health workers by allowing and encouraging the movement of often the best trained of these workers abroad. This migratory pattern complicates the training of replacements if health educators themselves are the ones migrating, as is often the case as destination countries recruit workers with the best credentials and most experience. Moreover, LCW migration can encourage a destructive cycle of migration where the loss of the most highly trained LCWs leads to increased stress, poorer working conditions and faster rates of worker attrition and migration for LCWs remaining in the source country, providing greater incentive for these remaining workers to migrate (Stilwell et al., 2003). The migration of health workers can have a significant, negative effect on health outcomes in source countries by making it more difficult to implement health interventions, overburdening staff and raising error rates in diagnoses and interventions, and reducing the capacity of health systems to use external funds and implement international health assistance programs (Kollar and Buyx, 2013). The desire of many student LCWs to migrate also has an impact on how these workers are trained, shifting priorities away from those of their home countries. As a result of the economic potential and increased demand for LCW migration, some health worker education systems, including nursing schools, have shifted to reflect requirements to work in destination countries. For example, in the Philippines, the desire for work abroad and the demand abroad for clinical and specialty nurses have resulted in a reduction of training opportunities for community health nurses (Dimaya et al., 2012). This trend creates considerable health and health equity concerns, as it results in the development of a health system that is unrepresentative of the country of origin’s health profile. Within LCW destination countries, there is concern that aging persons receiving care from these workers will have worse health outcomes and quality of life than if their caregivers had been trained domestically. The reasons for these concerns need not be founded in unwarranted bias against internationally trained LCWs. Rather, there is good reason for concern that the training received by these workers may not be fully appropriate for the context of their new country of residence, that these workers may not be appropriately licensed, that they may lack sufficient oversight from their new employers and that they will not receive adequate mentoring once in their destination, all problems that, while also faced by domestically trained LCWs, are exacerbated by their status as migrants (Eckenwiler, 2009). Less concretely, LCW migration can slow pressure for domestic reforms that are necessary to create an adequate supply of domestically trained LCWs. Reasons for this inadequate supply of workers can include insufficient investment in LCW training and poor working conditions, including inadequate pay, limited opportunities for advancement, discrimination and low social prestige associated with these jobs. If international LCWs can fill the gaps in domestic supply created by these problems, then there will less demand for economic and social changes needed to induce more people domestically to become LCWs (Eckenwiler, 2009). Despite the opportunities created through migration for LCWs, these workers and their families may themselves be harmed through migration. Most concretely, they may overestimate the employment opportunities and working conditions available abroad or be the victims of fraud or other forms of abuse once they have migrated. Some LCWs are paid informally, are in positions with little chance of advancement and only work part-time (Browne and Braun, 2008). LCWs are a vulnerable class due to the distances involved in travel, potential unfamiliarity with the language and culture in their destination country and, crucially, their status as non-citizen migrants. As a result, LCWs may take worse jobs than promised by recruiters or available at home in terms of wages, prestige or working conditions (Eckenwiler, 2009). These problems can be difficult to address because migrants who wish to emigrate permanently may be reluctant to complain about poor treatment for fear of losing their positions or being deported (Hosein and Thomas, 2007). For these reasons, migrant workers are especially vulnerable to sexual exploitation and other forms of abuse (Browne and Braun, 2008). Furthermore, licensure requirements may prevent these workers from working in the positions for which they are most qualified. As a result, they may enter the gray economy where they are paid under the table and thus do not receive benefits like health care and are especially vulnerable to exploitation (Meghani and Eckenwiler, 2009). This gap between the expected and actual benefits of migration helps to illustrate that while the gains experienced by migrant LCWs and their families might partially offset the negative health equity impacts of migration for residents of their home communities, these gains may be limited or non-existent. Women make up most of the caregiving and nursing workforce. Migrant LCWs from the Caribbean are primarily women of color and thus may be doubly disadvantaged. As a result, they take on most of the burden from increased stress and poorer working conditions at home resulting from nurse migration (Jones et al., 2009). Economic globalization channels many of these workers into devalued ‘women’s work’ including LCW roles that typically receive worse pay, benefits and respect than other work in the health field. In Canada, ‘black nurses’ have been found by the Ontario Human Rights Commission to have been more commonly placed into long-term care positions while ‘white nurses’ tended to be given the opportunity to choose their own specialties and positions (Hagey et al., 2001). The long-term caregiving industry often plays on cultural stereotypes; Caribbean workers are seen as naturally ‘warm-hearted and joyful’ and therefore naturally suited for the role of LCWs (Eckenwiler, 2012: 50). Migration by LCWs creates significant costs for their families as well, especially when dependent family members remain in the migrant’s home country (Jones et al., 2009). Dependent children are especially vulnerable to these problems, and migration by parents has been associated with youth delinquency in the Caribbean (Hosein and Thomas, 2007). In Trinidad and Tobago, for example, the children of parents who have migrated were found to be twice as likely to have mental health problems when compared to children whose parents had not migrated (Jones et al., 2004). Similarly, in Jamaica, 3 of every 10 households have children who are at risk for poor school performance, delinquent behavior and sexual abuse as a result of parents who have migrated abroad for work (Lofters, 2012). This separation creates mental health costs to the migrants as well, and separating from dependent children has been found to create especially high emotional costs for women (Jones et al., 2009). While these workers can in principle visit their families on a regular basis, their immigration status and the cost of doing so typically prevents this from happening in practice (Eckenwiler, 2009). Existing Policies toward Addressing these Impacts Numerous responses have been proposed with an aim toward reducing the international migration of LCWs and health workers generally and reducing the negative impacts of health worker migration. Some of these policies are aimed at reducing LCWs’ motivations to migrate or what are called ‘push’ factors for migration. As health workers have been found to be motivated to migrate due to poor wages, limited opportunities for advancement and limited training opportunities, source countries for these migrants can attempt to address these problems (World Bank, 2009). This solution is challenging, however, as source countries, including in the Caribbean, will have difficulty increasing their health care budgets as required by this solution (Snyder, 2014). Source countries can also increase training capacity (World Bank, 2009), but this step is also costly and does not ensure that new trainees will not migrate abroad as well. Other policies focus on reducing the attractiveness or availability of positions in relatively wealthy countries or what are called ‘pull’ factors for migration. Destination countries for migrants can reduce the need for migrant workers by increasing the domestic supply of workers. This can be achieved by improving working conditions domestically, including by improving wages or seeking to improve the social status of long-term caregiving work (Benatar, 2007). The need for domestic LCWs can be reduced as well through source policies that enable relatives of aging persons in need of care to take time away from paid work to serve as caregivers through receiving income assistance. Destination countries can also reduce opportunities for migration by placing legal limits on immigration from specific source countries, particularly those that have health worker shortages of their own. These limits can be placed unilaterally, bi-laterally in agreement with specific source countries as a form of managed migration or as part of a multi-lateral international framework aimed at limiting harmful forms of health worker migration (World Bank, 2009). Source countries can unilaterally take steps to reduce the attractiveness of positions abroad as well. Some countries have chosen to pursue locally appropriate training that will not translate well to the available technology and medical practices in destination countries (Eyal and Hurst, 2008). While potentially effective in stemming migration for technically demanding health worker positions, this approach is likely to be less successful for relatively low-skilled LCWs. Workers can be bonded into certain positions or locations as a requirement during their training, ensuring that source countries are compensated for the expense of health worker training (World Bank, 2009). This approach is not effective if workers receive private training or are brought out of their obligations by a source country employer and bonding has typically been used in training for higher skilled health worker positions. Finally, migrant workers can be taxed at the point of exiting their home country or on their income abroad to both compensate source countries for the loss of the workers’ skills and discourage emigration (World Bank, 2009). One such proposal, the so-called Bhagwati tax, seeks ongoing income tax revenue for a defined period via United Nations institutions on the income of skilled migrants who have gone abroad to work. Concerns about the use of these funds could be overcome by a requirement from the collecting institution that recipient source countries use the funds to offset the negative effects of migration. Countries such as the USA and the Philippines currently collect taxes on non-resident citizens, demonstrating the feasibility of this idea (Brock and Blake, 2015). Steps can also be taken to reduce the impact of existing patterns of LCW migration. This includes direct compensation by destination countries, largely aimed at compensating these countries for the expense of training the migrant worker but also for the impacts of the loss of these workers. As migrant health workers are difficult to replace as training requires time and the presence of skilled educators, simple cash compensation may not be effective in addressing the harms of migration (Snyder, 2014). Source countries can therefore also act to encourage training opportunities in destination countries, both by promoting time-limited training opportunities in destination countries and exchanges where health workers travel to source countries to provide training (World Bank, 2009). Finally, destination countries can act to protect migrant LCWs from the harms they may face from going abroad to work. These steps can including regularizing care worker employment to protect these workers from exploitation by employers and by requiring benefits and a living wage (Browne and Braun, 2008). While these steps would ensure these workers fair wages and protect them from some forms of abuse, perversely they would also serve to encourage increased migration given the more appealing working conditions available in destination countries. These policy responses are all potentially effective in reducing the rates and some forms of LCW migration. They face two significant limitations. First, many of these policies require participation by destination countries who stand to lose out financially or in terms of their eldercare options if they act to reduce the flow of migrant LCWs. As such, destination countries may be slow to enact policy reforms aimed at addressing the harms of LCW migration. While source countries can act unilaterally to reduce these flows, the policy options of locally relevant training and bonding are more appropriate to address the draw of more highly trained health worker positions in destination countries than less technically demanding long-term eldercare work, giving source countries fewer options. Second, these policy options assume that the problem of LCW migration must be addressed by reducing the flow of these workers or the harms caused by this flow. These policies do not consider whether the migratory flow could be to some extent reversed—namely by promoting the migration of those in need of long-term care to countries with workers who could care for them. While this form of migration would be at best a partial solution to the harms of LCW migration, in the remainder of this article, we will consider the feasibility and potential advantages of this approach specifically in the Caribbean. IRM and Long-Term Caregiving Transnational medical travel, or what is commonly called ‘medical tourism’, is the practice of individuals crossing international borders with the intention of seeking medical care paid for out-of-pocket. This practice has been cited as offering the potential to prevent skilled health workers from migrating and to encourage migrant health workers to return to their home countries by creating new jobs with relatively high wages and favorable working conditions (Bookman and Bookman, 2007). In addition, medical tourism can, in principle, generates tax revenues through new foreign exchange that can be used to support public health facilities accessed by the local population. Facilities targeting international patients typically lie outside the public health system of host countries, but they do provide an additional range of medical services for locals able to afford them and in this way prevents some members of the local population from becoming medical tourists themselves. As such, medical tourism can have positive impacts on host countries’ health human resource levels, economies and public health sectors (Beladi et al., 2015). There is a tacit assumption in the literature on care worker migration that aging persons in need of long-term care is fixed in place. We would like to consider whether, as is the case of medical tourism, promoting the movement of patients rather than caregiver populations might address some of the harms of LCW migration in a narrow set of cases, as may exist in the Caribbean. The practice of IRM is not new and typically takes the form of relatively wealthy retirees choosing to migrate temporarily or permanently across international borders, often with the goal of accessing warmer climates and/or a lower cost of living (Coates et al., 2002; Sunil et al., 2007; Toyota and Xiang, 2012). The warmer climates associated with IRM destinations have also been associated with positive health effects for these migrants (King et al., 2000; Wong and Musa, 2014). Flows of transnational retirees include from Northern Europe to Southern Europe (King et al., 1998), from Canada and the USA to Mexico (Sunil et al. 2007) and from Australia and Europe to Southeastern Asia (Abdul-Aziz et al., 2014). More recently, the opportunity for long-term home care has been considered a significant push factor for many US retirees who engage in IRM (Kiy and McEnany, 2010). While IRM has been historically driven by individuals seeking better climates and less expensive living conditions, several Southeastern Asian countries have taken a more aggressive approach to promoting this practice. The ‘Malaysia My Second Home’ program, for example, encourages IRM through easing laws around long-term residency and the purchase of property by non-citizens (Wong and Musa, 2014). Similarly, the Philippines has established the Philippine Retirement Authority and Thailand has used its Long-Stay and Healthcare Project to promote IRM given the perceived economic benefits of this practice (Toyota and Xiang, 2012). The Caribbean, by comparison, lags behind these countries in IRM though Barbados and St. Lucia among other Caribbean countries have historically attracted international retirees (Warnes, 2009). There is, however, increasing development around IRM in the Caribbean; for example, an international medical facility in Grand Cayman includes plans for a long-term care community (Stoner, 2015). This facility, development of which is scheduled to begin in 2015, will target US baby boomers on the basis of lower prices than are available in the USA for assisted living facilities (Duncan, 2015b). IRM can have a positive economic impact on destination countries and lead to job creation (Williams et al., 1997), including in the Caribbean (McElroy and De Albuquerque, 1992). These retirees tend to be relatively wealthy and, as long-term residents, make a much greater economic impact on the local economy than short-term tourists. Retirees bring in substantial financial and human capital into new communities, which can have a significant economic impact (Rojas et al., 2014). Partially, this is due to the demographic of retirement migrants, who require at least some level of financial capital to be able to engage in IRM (Sunil et al., 2007). In Mexico, US retirement migrants have a direct economic impact on destination communities through hiring local people to build homes, perform domestic labor, tend gardens and provide home care for spouses and other family members (Dixon et al., 2006). In Panama, local construction booms in some communities have shifted the economy from a focus on the relatively low-wage agricultural sector toward relatively better paying construction and service sector jobs catering to retirees (Dixon et al., 2006). Less is known about the impact of IRM on LCWs and destination country medical systems. However, there is good reason to think that employment offering long-term caregiving for international retirees in the caregivers’ home country would address at least some of the harms associated with the international migration of LCWs. This is likely given the assumption that at least some workers who would have emigrated to access better paying jobs abroad would prefer to accept even relatively less lucrative (but better than otherwise available) positions in facilities catering to international retirees. The advantages of IRM for Caribbean LCWs are the most apparent and least difficult to bring about. As migrants, these workers become particularly vulnerable to fraud or misinformation about the nature and terms of their employment abroad and to exploitation and coercion due to a fear of job loss and/or deportation. Living in their home countries, where they are protected by their domestic legal system and familiar with the local licensure requirements, culture and language, LCWs working in the domestic IRM field are more likely to be able to resist abusive working conditions. While choosing not to migrate does not protect these workers from domestic racial and gender discrimination, these workers will at least be more familiar with domestic norms and working conditions. These positions may be less likely to be informal, as they would be part of a relatively transparent international health sector and employees would enjoy the protection of their domestic legal system. As such, it is more likely that the improved working conditions expected by workers entering into these positions will be realized that is the case for migrants. The families of LCWs working in the domestic IRM sector are likely to benefit as well. Children of these workers will not be disadvantaged by separation from one or more parents nor will the workers suffer from time spent apart from their families. While wages in the domestic IRM sector may not be as high as those offered abroad, they will not need to be used on multiple households, international travel and higher costs of living abroad. While the take home pay of domestic workers may not match remittances from abroad, the overall advantage to these workers’ families of domestic IRM employment could be significant. Non-LCWs in IRM host countries may benefit from this sector as well. Within the source countries for migrant LCWs, retention of these workers through IRM will create the possibility that the public expenditures used in training these workers will not be lost through the migration of these workers. Similarly, if the most experienced and highly skilled LCWs choose not to migrate in favor of seeking positions in the IRM industry, these workers will still be potentially available to aid in training new LCWs. Crucially, these potential advantages for the health systems of source countries for migrants depend on whether the retained health workers interact with the public health system or work solely in the private IRM industry, completely disconnected from the systems that provide eldercare and LCW training domestically. This concern is shared with regard to the potential benefits of transnational medical travel, where health workers might be retained but isolated from the public health system (Chen and Flood, 2013; Snyder et al., 2013). At its worst, transnational medical travel and IRM could actually encourage increased health worker migration from the public to private health sectors, actually worsening health human resource challenges domestically given the ease of public to private sector migration over international migration (Hall, 2011). To ensure that IRM improves or at least does not worsen LCW staffing in the public system, Caribbean countries would need to promote development of the IRM industry around shared staffing and training opportunities. Such provisions have been attempted previously in the Caribbean. For example, the Health City Cayman Islands development offers training opportunities for Caymanian high school students (Duncan, 2015a). A similar worry with promoting IRM as a way of retaining LCMs is that international retirees might strain the local health system and crowd out other residents from accessing medical services. As these retirees will be at an age where they can be expected to have increased medical needs, these migrants can be expected to create greater demands on the local health system than the population at large. In fact, IRM developments tend to emphasize the quality of the local health system to prospective customers, making the case that they will be able to access these services (Warnes, 2009). As with the concern that IRM will undermine public access to care workers in host countries, the concern that local residents will be crowded out from accessing health care means that IRM facilities should be developed and regulated with an eye toward avoiding this problem. Potential solutions include developing medical facilities specifically designed to service retirement migrants so that public resources will not be diverted to these private enterprises. The proposed retirement center in Grand Cayman follows this model by pairing the proposed center with custom built medical facilities (Stoner, 2015). Additionally, countries seeking to enter the IRM market should ensure that revenues from these developments be directed at addressing any concerns with crowding out local residents by increasing health system capacity including by increasing health worker training capacity. While stemming LCW migration through promotion of the IRM sector does not guarantee benefits to these workers, their families and their communities, there are good reasons to think that, if properly managed, these benefits could be generated. As such, IRM should be part of the set of policy options considered for those states that have the climate and capacity to host IRMs and the institutional controls needed to manage its development to the benefit of the domestic population. Creating a New Injustice for the Vulnerable Aging Persons? While using IRM to address LCW migration would require careful development and regulation to genuinely benefit host country populations and LCWs, it is at the very least a policy option that should be explored by Caribbean nations and other potential IRM exporters. IRM has this potential by refusing to assume that aging persons in relatively wealthy countries should remain in their home countries, instead using the problematic nature of LCW migration to justify encouraging the international migration of aging persons. However, there is good reason to be wary that this means of promoting a more equitable global distribution of LCWs would come at the cost of treating aging persons unjustly. If aging persons are compelled to migrate to access adequate long-term care, then they would arguably be denied a human right to health care (provided by either professional or informal caregivers) or have unacceptably demanding conditions placed on accessing this care. Moreover, as a vulnerable population, many aging persons would find migrating for long-term care extremely onerous. Such migration would be taxing on the health of many aging persons and require separation from family and community support. Given this concern, it is important to note that IRM should not and almost certainly would not be compulsory for aging persons. A shift to promoting IRM would help host countries offer alternatives to migration by their LCWs, but aging persons in relatively wealthy countries would still have access to LCWs through migration from other countries and domestic populations of these workers. While some insurance companies have explored offering inducements for customers to access less expensive treatment abroad, such travel has not been mandatory (Cohen, 2014) and this is unlikely and undesirable in the case of long-term care as well. Moreover, it is a mistake to think of aging persons as an undifferentiated group on whom the label ‘vulnerable’ can be applied equally. As Florencia Luna (2014) notes, aging persons can face many different layers of vulnerability, including economic, housing and relationship vulnerability. The option of pursuing IRM will potentially help reduce some of these vulnerabilities. Economic and housing vulnerability would be reduced if IRM were to provide additional housing options at a lower price than is available in the retiree’s home country. If the quality of care offered by these facilities is as good as or better than that in the retiree’s home country, physical and cognitive vulnerabilities might be addressed as well. As long-term home care in countries like the USA is often fragmented by high turnover among LCWs (Eckenwiler, 2012), dedicated long-term care facilities in the Caribbean may have an advantage over consumer-directed care in the USA. The form of vulnerability most likely to be increased by IRM is relationship vulnerability. This vulnerability is present now for many aging persons, as the families of aging persons are increasingly small and unable or unwilling to care for them in their own homes. As a result, many aging persons feel isolated from their families, which can in turn worsen other layers of vulnerability (Luna, 2014). IRM might increase this vulnerability by adding to the geographic distance separating aging persons from their families and decreasing opportunities for contact with friends and family members in the retiree’s home community. Depending on an individuals’ existing relationships and other layers of vulnerability, IRM will be an option that would worsen the vulnerability of some while reducing it for others. Conclusion One advantage of IRM as a strategy for reducing LCW migration is that host countries can pursue a policy of promoting IRM without the cooperation of LCW destination countries. As these LCW destination countries benefit from LCW migration, many have been slow to address this migration or have actively promoted it. That said, without support from LCW destinations, IRM is likely to be restricted to those persons who have the wealth needed to retire abroad, thus limiting the overall scope and benefit of IRM for host countries in the Caribbean. As a result, this approach to reducing problematic LCW migration would have a greater impact if supported policies promoting IRM from wealthy countries, including health insurance and pension portability (Coates et al., 2002). For example, if the USA were to extend Medicare coverage for Americans living abroad, then the potential customer base for IRM destinations would be greatly expanded. IRM is a limited solution to the enormous problem of LCW migration. IRM is suitable to a narrow range of countries with the climate and infrastructure to support this industry. To ensure that IRM is beneficial to LCWs and IRM host country populations, this industry must be carefully regulated. IRM is a suitable option for only a subset of aging persons of LCW destination countries, and this subset is limited by destination country policies that do not support insurance and pension portability. That said, in fighting against LCW migration, more policy options are better than fewer and IRM should be taken seriously as an additional and ethically defensible policy option. Private investors will pursue IRM as an economic opportunity regardless of whether it is seen as a tool in combating LCW migration. It is in the best interest of LCWs, their families and their home countries if this development is guided in a way that supports global health equity. Acknowledgements Thanks for feedback on an earlier draft of this article from Johanna Hanefeld and seminar participants at the London School of Hygiene and Tropical Medicine. 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Can We Care for Aging Persons without Worsening Global Inequities? The Case of Long-Term Care Worker Migration from the Anglophone Caribbean

Snyder,, Jeremy; Crooks, Valorie, A
Public Health Ethics , Volume 10 (3) – Nov 1, 2017
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Oxford University Press
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© The Author 2016. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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1754-9973
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1754-9981
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10.1093/phe/phw031
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Abstract

Abstract The international migration of health workers, including long-term care workers (LCWs) for aging populations, contributes to a shortage of these workers in many parts of the world. In the Anglophone Caribbean, LCW shortages and the migration of nurses to take on LCW positions abroad threaten the health of local populations and widen global inequities in health. Many responses have been proposed to address the international migration of health workers generally, including making it more difficult for these workers to emigrate and increasing and improving local employment opportunities. In this article, we suggest an additional means of ethically reducing health worker migration, targeting the Anglophone Caribbean specifically. Countries in this region can take advantage of their warmer climate and well-trained work force to encourage aging populations in the global north to emigrate temporarily or permanently through international retirement migration. As a result, countries in the Anglophone Caribbean can not only decrease the international migration of trained health workers through the provision of well-paying, local jobs, but potentially reverse this flow by drawing on the international diaspora of their workers. International retirement migration, if carefully managed, can reduce global inequities in health while treating both retirees and LCWs ethically. In wealthy countries such as Canada and the USA, a shift in the culture of care away from institutionalization and toward home and community-based care, along with demographic shifts toward older populations, has resulted in a dramatic increase in demand for long-term care workers (LCWs) such as homecare nurses and care aides (Eckenwiler, 2012). As a result, long-term care jobs, such as Home Health Aides and Personal Care Aides, are projected to be the third and fourth fastest-growing occupations in the USA between 2008 and 2018 (Paraprofessional Health Institute, 2011), respectively. Work performed by LCWs often centers around core activities of daily living, such as bathing and eating, and therefore is likely to influence not only a patient’s quality of care but quality of life. LCWs have more contact with care recipients than physicians, heavily influencing quality of care (Stone and Harahan, 2010). As a result, insufficient numbers of LCWs will drastically and negatively impact quality of life for aging persons as demand for LCWs increases. LCWs are often poorly paid in high-income countries and face poor working conditions, including poor occupational and safety standards and physically demanding job requirements. As a result, employers often find it difficult to staff these positions from the existing supply of resident workers (Browne and Braun, 2008). For this reason, long-term caregiving positions are sometimes filled by migrant workers who are attracted to these positions by higher wages and better career opportunities than are available in their home countries (Eckenwiler, 2012). Flows of LCWs are influenced by the impacts of colonization, with factors such as language fluency, nursing culture and training culture all contributing to migration patterns (Redfoot and Houser, 2008). Other factors, such as geographic proximity and prioritized work visa initiatives, play an important role in influencing migratory flows. In Europe, nations in Central and Western Europe increasingly source nurses from Eastern Europe (Redfoot and Houser, 2008). Intra-regional and stepwise movement of LCWs occurs within Africa as well, such as from the Democratic Republic of the Congo to Kenya and from Kenya to South Africa, Namibia and Botswana. Many African nations, such as South Africa, are both destination and source countries for LCWs (Connell et al., 2007). The active recruitment of LCWs (where recruiters take positive steps to encourage and facilitate migration) also influences migration patterns. Lofters (2012) suggests active recruitment from wealthy countries is a major driving force for Anglophone Caribbean nurse migration, stating that in 2006, 41 per cent of migrant nurses in Britain reported migrating there because of recruitment. Indeed, the growing demand for LCWs has contributed to the rapid growth of for-profit international recruitment industry, related to recruitment, testing, credentialing and immigration (Eckenwiler, 2012). We contend that transnational patterns of LCW migration have significant implications for global health equity for LCW source countries, LCW destination countries and LCWs themselves. By ‘global health equity’, we refer to differences, from the local to the international scale, in access to the resources necessary to maintain a reasonable standard of health and well-being that are not naturally occurring and are unfair or unjust. In this article, we identify these inequities and policies that have been advocated for reducing them, focusing on LCW migration from the Caribbean. We then suggest that Anglophone Caribbean nations in particular should take a lesson from international health travel (or ‘medical tourism’) and consider promoting international retirement migration (IRM) as an additional tool for more equitably addressing the global demand for LCWs. The Caribbean Context The Anglophone Caribbean region has historically struggled to retain health workers that serve as eldercare workers abroad. This is true particularly in the English-speaking Caribbean where health workers’ language skills create employment opportunities in Canada, the USA and the UK, among other countries. An examination of the outflow of nurses from the Caribbean is illustrative of this problem, though LCWs are not drawn exclusively from the nursing ranks nor do Caribbean nurses migrate only to take on LCW positions. Data on nurse migration is much better than for most other categories of health workers in the Caribbean, however, and examining these data gives a general sense of the scope of the problem. Migration out of the Caribbean region is the main cause of nurse attrition within that region (World Bank, 2009). In 2009, it was estimated that there were 21,000 Caribbean-trained nurses working in North America (15,500 USA, 750 Canada) and the UK (4750) compared with only 7800 remaining in the Caribbean—a shocking ratio of three times the number of Caribbean-trained nurses working outside of the Caribbean compared to within the Caribbean—though the pace of this migration was slowing at the time (World Bank, 2009). In 2007, it was estimated that the percentage of nurses leaving for Organization for Economic Co-operation and Development (OECD) countries was above 70 per cent for most of the Caribbean, including 88 per cent for Jamaica and 78 per cent for Barbados (Dumont and Zurn, 2007). This migration of nurses and other health workers has led to a health worker shortage throughout the Caribbean. The World Bank (2009) found 2700 nursing vacancies within the region. Vacancy rates vary by country, with nursing vacancy rates of 20.6 per cent in Barbados, 58.4 per cent in Jamaica, 26 per cent in St. Kitts and 53.3 per cent in Trinidad and Tobago and a regional average of 35 per cent (Hosein and Thomas, 2007). Jamaica has been calculated to lose 8 per cent of its nurses and 20 per cent of its specialist nurses to international migration each year (Wyss, 2004). Barbados saw numbers of registered nurses fall from 701 in 2002 to 551 in 2004 (Sealy, 2011). Nurses from the Caribbean are motivated to emigrate due to low pay at home, poor working conditions in local private and public facilities, limited career advancement opportunities, limited employment opportunities in their home countries, lack of job security and occupational risks. By comparison, countries like the USA, Canada and UK offer higher nominal and real incomes, a better standard of living, better working conditions, better educational and training opportunities and the opportunity to improve the lives of family members through remittances (Caribbean Commission on Health and Development, 2006; Sealy, 2011). While many Caribbean-trained nurses go abroad to serve in nursing positions, others will accept LCW positions because their nursing credentials are not accepted in their destination country or to gain a foothold in a new country with the aim of eventually gaining employment in a nursing position. Thus, LCW positions serve as an additional draw for trained nurses in the Caribbean to migrate abroad (Eckenwiler, 2012). The educational capacity in the region is insufficient to replace these workers, and this problem is exacerbated by the loss of the best trained and most experienced workers, some of whom staff these educational facilities, resulting in a reduced capacity to train new workers (Salmon et al., 2007). Top graduates of nursing training programs were also seen to be most likely to migrate abroad, undermining the development of a new generation of educators and leaders in the field (World Bank, 2009). Losses of health workers in one part of the Caribbean can worsen shortfalls in other parts of the region as well. Countries like Jamaica have turned to other, less affluent Caribbean countries to meet their domestic health worker shortfall, spreading the effects of health worker migration (Salmon et al., 2007). The population in the Caribbean is aging, creating increased regional demand for eldercare that create additional demands on already insufficient LCW resources Emigration by the children of aging Caribbeans reduces the number of informal family caregivers available and creates further demand for professional caregivers (Eckenwiler, 2012). As a result, demand for health workers, including LCWs, will only increase in the Caribbean, worsening the impact of shortfalls in the supply of these workers. Global Health Equity Impacts The transnational migration of LCWs is motivated by the prospect of new and better employment opportunities for these workers and, often, the prospect of helping families left behind by sending them remittances. In Jamaica, remittances account for nearly 20 per cent of national gross domestic product (Lofters, 2012). However, this pattern of migration also creates significant negative consequences for a range of groups, including members of the migrants’ home countries, members of the migrants’ destination countries and for the migrants themselves and their families. The primary equity concern with LCW out migration is that it further worsens existing shortages of these workers in their home countries. As discussed above, the Anglophone Caribbean region and many other low- to middle-income regions have had difficulty training and retaining adequate numbers of these workers, particularly skilled health workers such as nurses. Due to the loss of these workers, some source countries have a more difficult time meeting their own eldercare needs (Salmon et al., 2007; Eckenwiler, 2009). This pattern of migration leads to an unjust redistribution of resources from less economically developed countries to richer nations. Destination countries lose out on the investments they have placed in training these workers while receiving little or nothing in return (Jones et al., 2009). Costs of nurse migration to the Caribbean Community and Common Market region were estimated at US$16 million in 2001 (Thomas et al., 2005). In Jamaica, many nursing students enter training already with firm plans to migrate, meaning that this country will receive nothing in return for its investment in training these workers (WHO, 2010). LCWs who migrate abroad for work often do so to obtain higher wages and to send some portion of these wages home to their families as remittances. However, remittances from workers who migrate abroad remain insignificant among the poorest and most marginalized members of these communities (Kalipeni et al., 2012) and the multiple adverse social and economic costs of migration to national economies and health systems are generally thought not to be offset by the flow of remittances (Lofters, 2012). LCW migration worsens problems with retaining adequate numbers of health workers by allowing and encouraging the movement of often the best trained of these workers abroad. This migratory pattern complicates the training of replacements if health educators themselves are the ones migrating, as is often the case as destination countries recruit workers with the best credentials and most experience. Moreover, LCW migration can encourage a destructive cycle of migration where the loss of the most highly trained LCWs leads to increased stress, poorer working conditions and faster rates of worker attrition and migration for LCWs remaining in the source country, providing greater incentive for these remaining workers to migrate (Stilwell et al., 2003). The migration of health workers can have a significant, negative effect on health outcomes in source countries by making it more difficult to implement health interventions, overburdening staff and raising error rates in diagnoses and interventions, and reducing the capacity of health systems to use external funds and implement international health assistance programs (Kollar and Buyx, 2013). The desire of many student LCWs to migrate also has an impact on how these workers are trained, shifting priorities away from those of their home countries. As a result of the economic potential and increased demand for LCW migration, some health worker education systems, including nursing schools, have shifted to reflect requirements to work in destination countries. For example, in the Philippines, the desire for work abroad and the demand abroad for clinical and specialty nurses have resulted in a reduction of training opportunities for community health nurses (Dimaya et al., 2012). This trend creates considerable health and health equity concerns, as it results in the development of a health system that is unrepresentative of the country of origin’s health profile. Within LCW destination countries, there is concern that aging persons receiving care from these workers will have worse health outcomes and quality of life than if their caregivers had been trained domestically. The reasons for these concerns need not be founded in unwarranted bias against internationally trained LCWs. Rather, there is good reason for concern that the training received by these workers may not be fully appropriate for the context of their new country of residence, that these workers may not be appropriately licensed, that they may lack sufficient oversight from their new employers and that they will not receive adequate mentoring once in their destination, all problems that, while also faced by domestically trained LCWs, are exacerbated by their status as migrants (Eckenwiler, 2009). Less concretely, LCW migration can slow pressure for domestic reforms that are necessary to create an adequate supply of domestically trained LCWs. Reasons for this inadequate supply of workers can include insufficient investment in LCW training and poor working conditions, including inadequate pay, limited opportunities for advancement, discrimination and low social prestige associated with these jobs. If international LCWs can fill the gaps in domestic supply created by these problems, then there will less demand for economic and social changes needed to induce more people domestically to become LCWs (Eckenwiler, 2009). Despite the opportunities created through migration for LCWs, these workers and their families may themselves be harmed through migration. Most concretely, they may overestimate the employment opportunities and working conditions available abroad or be the victims of fraud or other forms of abuse once they have migrated. Some LCWs are paid informally, are in positions with little chance of advancement and only work part-time (Browne and Braun, 2008). LCWs are a vulnerable class due to the distances involved in travel, potential unfamiliarity with the language and culture in their destination country and, crucially, their status as non-citizen migrants. As a result, LCWs may take worse jobs than promised by recruiters or available at home in terms of wages, prestige or working conditions (Eckenwiler, 2009). These problems can be difficult to address because migrants who wish to emigrate permanently may be reluctant to complain about poor treatment for fear of losing their positions or being deported (Hosein and Thomas, 2007). For these reasons, migrant workers are especially vulnerable to sexual exploitation and other forms of abuse (Browne and Braun, 2008). Furthermore, licensure requirements may prevent these workers from working in the positions for which they are most qualified. As a result, they may enter the gray economy where they are paid under the table and thus do not receive benefits like health care and are especially vulnerable to exploitation (Meghani and Eckenwiler, 2009). This gap between the expected and actual benefits of migration helps to illustrate that while the gains experienced by migrant LCWs and their families might partially offset the negative health equity impacts of migration for residents of their home communities, these gains may be limited or non-existent. Women make up most of the caregiving and nursing workforce. Migrant LCWs from the Caribbean are primarily women of color and thus may be doubly disadvantaged. As a result, they take on most of the burden from increased stress and poorer working conditions at home resulting from nurse migration (Jones et al., 2009). Economic globalization channels many of these workers into devalued ‘women’s work’ including LCW roles that typically receive worse pay, benefits and respect than other work in the health field. In Canada, ‘black nurses’ have been found by the Ontario Human Rights Commission to have been more commonly placed into long-term care positions while ‘white nurses’ tended to be given the opportunity to choose their own specialties and positions (Hagey et al., 2001). The long-term caregiving industry often plays on cultural stereotypes; Caribbean workers are seen as naturally ‘warm-hearted and joyful’ and therefore naturally suited for the role of LCWs (Eckenwiler, 2012: 50). Migration by LCWs creates significant costs for their families as well, especially when dependent family members remain in the migrant’s home country (Jones et al., 2009). Dependent children are especially vulnerable to these problems, and migration by parents has been associated with youth delinquency in the Caribbean (Hosein and Thomas, 2007). In Trinidad and Tobago, for example, the children of parents who have migrated were found to be twice as likely to have mental health problems when compared to children whose parents had not migrated (Jones et al., 2004). Similarly, in Jamaica, 3 of every 10 households have children who are at risk for poor school performance, delinquent behavior and sexual abuse as a result of parents who have migrated abroad for work (Lofters, 2012). This separation creates mental health costs to the migrants as well, and separating from dependent children has been found to create especially high emotional costs for women (Jones et al., 2009). While these workers can in principle visit their families on a regular basis, their immigration status and the cost of doing so typically prevents this from happening in practice (Eckenwiler, 2009). Existing Policies toward Addressing these Impacts Numerous responses have been proposed with an aim toward reducing the international migration of LCWs and health workers generally and reducing the negative impacts of health worker migration. Some of these policies are aimed at reducing LCWs’ motivations to migrate or what are called ‘push’ factors for migration. As health workers have been found to be motivated to migrate due to poor wages, limited opportunities for advancement and limited training opportunities, source countries for these migrants can attempt to address these problems (World Bank, 2009). This solution is challenging, however, as source countries, including in the Caribbean, will have difficulty increasing their health care budgets as required by this solution (Snyder, 2014). Source countries can also increase training capacity (World Bank, 2009), but this step is also costly and does not ensure that new trainees will not migrate abroad as well. Other policies focus on reducing the attractiveness or availability of positions in relatively wealthy countries or what are called ‘pull’ factors for migration. Destination countries for migrants can reduce the need for migrant workers by increasing the domestic supply of workers. This can be achieved by improving working conditions domestically, including by improving wages or seeking to improve the social status of long-term caregiving work (Benatar, 2007). The need for domestic LCWs can be reduced as well through source policies that enable relatives of aging persons in need of care to take time away from paid work to serve as caregivers through receiving income assistance. Destination countries can also reduce opportunities for migration by placing legal limits on immigration from specific source countries, particularly those that have health worker shortages of their own. These limits can be placed unilaterally, bi-laterally in agreement with specific source countries as a form of managed migration or as part of a multi-lateral international framework aimed at limiting harmful forms of health worker migration (World Bank, 2009). Source countries can unilaterally take steps to reduce the attractiveness of positions abroad as well. Some countries have chosen to pursue locally appropriate training that will not translate well to the available technology and medical practices in destination countries (Eyal and Hurst, 2008). While potentially effective in stemming migration for technically demanding health worker positions, this approach is likely to be less successful for relatively low-skilled LCWs. Workers can be bonded into certain positions or locations as a requirement during their training, ensuring that source countries are compensated for the expense of health worker training (World Bank, 2009). This approach is not effective if workers receive private training or are brought out of their obligations by a source country employer and bonding has typically been used in training for higher skilled health worker positions. Finally, migrant workers can be taxed at the point of exiting their home country or on their income abroad to both compensate source countries for the loss of the workers’ skills and discourage emigration (World Bank, 2009). One such proposal, the so-called Bhagwati tax, seeks ongoing income tax revenue for a defined period via United Nations institutions on the income of skilled migrants who have gone abroad to work. Concerns about the use of these funds could be overcome by a requirement from the collecting institution that recipient source countries use the funds to offset the negative effects of migration. Countries such as the USA and the Philippines currently collect taxes on non-resident citizens, demonstrating the feasibility of this idea (Brock and Blake, 2015). Steps can also be taken to reduce the impact of existing patterns of LCW migration. This includes direct compensation by destination countries, largely aimed at compensating these countries for the expense of training the migrant worker but also for the impacts of the loss of these workers. As migrant health workers are difficult to replace as training requires time and the presence of skilled educators, simple cash compensation may not be effective in addressing the harms of migration (Snyder, 2014). Source countries can therefore also act to encourage training opportunities in destination countries, both by promoting time-limited training opportunities in destination countries and exchanges where health workers travel to source countries to provide training (World Bank, 2009). Finally, destination countries can act to protect migrant LCWs from the harms they may face from going abroad to work. These steps can including regularizing care worker employment to protect these workers from exploitation by employers and by requiring benefits and a living wage (Browne and Braun, 2008). While these steps would ensure these workers fair wages and protect them from some forms of abuse, perversely they would also serve to encourage increased migration given the more appealing working conditions available in destination countries. These policy responses are all potentially effective in reducing the rates and some forms of LCW migration. They face two significant limitations. First, many of these policies require participation by destination countries who stand to lose out financially or in terms of their eldercare options if they act to reduce the flow of migrant LCWs. As such, destination countries may be slow to enact policy reforms aimed at addressing the harms of LCW migration. While source countries can act unilaterally to reduce these flows, the policy options of locally relevant training and bonding are more appropriate to address the draw of more highly trained health worker positions in destination countries than less technically demanding long-term eldercare work, giving source countries fewer options. Second, these policy options assume that the problem of LCW migration must be addressed by reducing the flow of these workers or the harms caused by this flow. These policies do not consider whether the migratory flow could be to some extent reversed—namely by promoting the migration of those in need of long-term care to countries with workers who could care for them. While this form of migration would be at best a partial solution to the harms of LCW migration, in the remainder of this article, we will consider the feasibility and potential advantages of this approach specifically in the Caribbean. IRM and Long-Term Caregiving Transnational medical travel, or what is commonly called ‘medical tourism’, is the practice of individuals crossing international borders with the intention of seeking medical care paid for out-of-pocket. This practice has been cited as offering the potential to prevent skilled health workers from migrating and to encourage migrant health workers to return to their home countries by creating new jobs with relatively high wages and favorable working conditions (Bookman and Bookman, 2007). In addition, medical tourism can, in principle, generates tax revenues through new foreign exchange that can be used to support public health facilities accessed by the local population. Facilities targeting international patients typically lie outside the public health system of host countries, but they do provide an additional range of medical services for locals able to afford them and in this way prevents some members of the local population from becoming medical tourists themselves. As such, medical tourism can have positive impacts on host countries’ health human resource levels, economies and public health sectors (Beladi et al., 2015). There is a tacit assumption in the literature on care worker migration that aging persons in need of long-term care is fixed in place. We would like to consider whether, as is the case of medical tourism, promoting the movement of patients rather than caregiver populations might address some of the harms of LCW migration in a narrow set of cases, as may exist in the Caribbean. The practice of IRM is not new and typically takes the form of relatively wealthy retirees choosing to migrate temporarily or permanently across international borders, often with the goal of accessing warmer climates and/or a lower cost of living (Coates et al., 2002; Sunil et al., 2007; Toyota and Xiang, 2012). The warmer climates associated with IRM destinations have also been associated with positive health effects for these migrants (King et al., 2000; Wong and Musa, 2014). Flows of transnational retirees include from Northern Europe to Southern Europe (King et al., 1998), from Canada and the USA to Mexico (Sunil et al. 2007) and from Australia and Europe to Southeastern Asia (Abdul-Aziz et al., 2014). More recently, the opportunity for long-term home care has been considered a significant push factor for many US retirees who engage in IRM (Kiy and McEnany, 2010). While IRM has been historically driven by individuals seeking better climates and less expensive living conditions, several Southeastern Asian countries have taken a more aggressive approach to promoting this practice. The ‘Malaysia My Second Home’ program, for example, encourages IRM through easing laws around long-term residency and the purchase of property by non-citizens (Wong and Musa, 2014). Similarly, the Philippines has established the Philippine Retirement Authority and Thailand has used its Long-Stay and Healthcare Project to promote IRM given the perceived economic benefits of this practice (Toyota and Xiang, 2012). The Caribbean, by comparison, lags behind these countries in IRM though Barbados and St. Lucia among other Caribbean countries have historically attracted international retirees (Warnes, 2009). There is, however, increasing development around IRM in the Caribbean; for example, an international medical facility in Grand Cayman includes plans for a long-term care community (Stoner, 2015). This facility, development of which is scheduled to begin in 2015, will target US baby boomers on the basis of lower prices than are available in the USA for assisted living facilities (Duncan, 2015b). IRM can have a positive economic impact on destination countries and lead to job creation (Williams et al., 1997), including in the Caribbean (McElroy and De Albuquerque, 1992). These retirees tend to be relatively wealthy and, as long-term residents, make a much greater economic impact on the local economy than short-term tourists. Retirees bring in substantial financial and human capital into new communities, which can have a significant economic impact (Rojas et al., 2014). Partially, this is due to the demographic of retirement migrants, who require at least some level of financial capital to be able to engage in IRM (Sunil et al., 2007). In Mexico, US retirement migrants have a direct economic impact on destination communities through hiring local people to build homes, perform domestic labor, tend gardens and provide home care for spouses and other family members (Dixon et al., 2006). In Panama, local construction booms in some communities have shifted the economy from a focus on the relatively low-wage agricultural sector toward relatively better paying construction and service sector jobs catering to retirees (Dixon et al., 2006). Less is known about the impact of IRM on LCWs and destination country medical systems. However, there is good reason to think that employment offering long-term caregiving for international retirees in the caregivers’ home country would address at least some of the harms associated with the international migration of LCWs. This is likely given the assumption that at least some workers who would have emigrated to access better paying jobs abroad would prefer to accept even relatively less lucrative (but better than otherwise available) positions in facilities catering to international retirees. The advantages of IRM for Caribbean LCWs are the most apparent and least difficult to bring about. As migrants, these workers become particularly vulnerable to fraud or misinformation about the nature and terms of their employment abroad and to exploitation and coercion due to a fear of job loss and/or deportation. Living in their home countries, where they are protected by their domestic legal system and familiar with the local licensure requirements, culture and language, LCWs working in the domestic IRM field are more likely to be able to resist abusive working conditions. While choosing not to migrate does not protect these workers from domestic racial and gender discrimination, these workers will at least be more familiar with domestic norms and working conditions. These positions may be less likely to be informal, as they would be part of a relatively transparent international health sector and employees would enjoy the protection of their domestic legal system. As such, it is more likely that the improved working conditions expected by workers entering into these positions will be realized that is the case for migrants. The families of LCWs working in the domestic IRM sector are likely to benefit as well. Children of these workers will not be disadvantaged by separation from one or more parents nor will the workers suffer from time spent apart from their families. While wages in the domestic IRM sector may not be as high as those offered abroad, they will not need to be used on multiple households, international travel and higher costs of living abroad. While the take home pay of domestic workers may not match remittances from abroad, the overall advantage to these workers’ families of domestic IRM employment could be significant. Non-LCWs in IRM host countries may benefit from this sector as well. Within the source countries for migrant LCWs, retention of these workers through IRM will create the possibility that the public expenditures used in training these workers will not be lost through the migration of these workers. Similarly, if the most experienced and highly skilled LCWs choose not to migrate in favor of seeking positions in the IRM industry, these workers will still be potentially available to aid in training new LCWs. Crucially, these potential advantages for the health systems of source countries for migrants depend on whether the retained health workers interact with the public health system or work solely in the private IRM industry, completely disconnected from the systems that provide eldercare and LCW training domestically. This concern is shared with regard to the potential benefits of transnational medical travel, where health workers might be retained but isolated from the public health system (Chen and Flood, 2013; Snyder et al., 2013). At its worst, transnational medical travel and IRM could actually encourage increased health worker migration from the public to private health sectors, actually worsening health human resource challenges domestically given the ease of public to private sector migration over international migration (Hall, 2011). To ensure that IRM improves or at least does not worsen LCW staffing in the public system, Caribbean countries would need to promote development of the IRM industry around shared staffing and training opportunities. Such provisions have been attempted previously in the Caribbean. For example, the Health City Cayman Islands development offers training opportunities for Caymanian high school students (Duncan, 2015a). A similar worry with promoting IRM as a way of retaining LCMs is that international retirees might strain the local health system and crowd out other residents from accessing medical services. As these retirees will be at an age where they can be expected to have increased medical needs, these migrants can be expected to create greater demands on the local health system than the population at large. In fact, IRM developments tend to emphasize the quality of the local health system to prospective customers, making the case that they will be able to access these services (Warnes, 2009). As with the concern that IRM will undermine public access to care workers in host countries, the concern that local residents will be crowded out from accessing health care means that IRM facilities should be developed and regulated with an eye toward avoiding this problem. Potential solutions include developing medical facilities specifically designed to service retirement migrants so that public resources will not be diverted to these private enterprises. The proposed retirement center in Grand Cayman follows this model by pairing the proposed center with custom built medical facilities (Stoner, 2015). Additionally, countries seeking to enter the IRM market should ensure that revenues from these developments be directed at addressing any concerns with crowding out local residents by increasing health system capacity including by increasing health worker training capacity. While stemming LCW migration through promotion of the IRM sector does not guarantee benefits to these workers, their families and their communities, there are good reasons to think that, if properly managed, these benefits could be generated. As such, IRM should be part of the set of policy options considered for those states that have the climate and capacity to host IRMs and the institutional controls needed to manage its development to the benefit of the domestic population. Creating a New Injustice for the Vulnerable Aging Persons? While using IRM to address LCW migration would require careful development and regulation to genuinely benefit host country populations and LCWs, it is at the very least a policy option that should be explored by Caribbean nations and other potential IRM exporters. IRM has this potential by refusing to assume that aging persons in relatively wealthy countries should remain in their home countries, instead using the problematic nature of LCW migration to justify encouraging the international migration of aging persons. However, there is good reason to be wary that this means of promoting a more equitable global distribution of LCWs would come at the cost of treating aging persons unjustly. If aging persons are compelled to migrate to access adequate long-term care, then they would arguably be denied a human right to health care (provided by either professional or informal caregivers) or have unacceptably demanding conditions placed on accessing this care. Moreover, as a vulnerable population, many aging persons would find migrating for long-term care extremely onerous. Such migration would be taxing on the health of many aging persons and require separation from family and community support. Given this concern, it is important to note that IRM should not and almost certainly would not be compulsory for aging persons. A shift to promoting IRM would help host countries offer alternatives to migration by their LCWs, but aging persons in relatively wealthy countries would still have access to LCWs through migration from other countries and domestic populations of these workers. While some insurance companies have explored offering inducements for customers to access less expensive treatment abroad, such travel has not been mandatory (Cohen, 2014) and this is unlikely and undesirable in the case of long-term care as well. Moreover, it is a mistake to think of aging persons as an undifferentiated group on whom the label ‘vulnerable’ can be applied equally. As Florencia Luna (2014) notes, aging persons can face many different layers of vulnerability, including economic, housing and relationship vulnerability. The option of pursuing IRM will potentially help reduce some of these vulnerabilities. Economic and housing vulnerability would be reduced if IRM were to provide additional housing options at a lower price than is available in the retiree’s home country. If the quality of care offered by these facilities is as good as or better than that in the retiree’s home country, physical and cognitive vulnerabilities might be addressed as well. As long-term home care in countries like the USA is often fragmented by high turnover among LCWs (Eckenwiler, 2012), dedicated long-term care facilities in the Caribbean may have an advantage over consumer-directed care in the USA. The form of vulnerability most likely to be increased by IRM is relationship vulnerability. This vulnerability is present now for many aging persons, as the families of aging persons are increasingly small and unable or unwilling to care for them in their own homes. As a result, many aging persons feel isolated from their families, which can in turn worsen other layers of vulnerability (Luna, 2014). IRM might increase this vulnerability by adding to the geographic distance separating aging persons from their families and decreasing opportunities for contact with friends and family members in the retiree’s home community. Depending on an individuals’ existing relationships and other layers of vulnerability, IRM will be an option that would worsen the vulnerability of some while reducing it for others. Conclusion One advantage of IRM as a strategy for reducing LCW migration is that host countries can pursue a policy of promoting IRM without the cooperation of LCW destination countries. As these LCW destination countries benefit from LCW migration, many have been slow to address this migration or have actively promoted it. That said, without support from LCW destinations, IRM is likely to be restricted to those persons who have the wealth needed to retire abroad, thus limiting the overall scope and benefit of IRM for host countries in the Caribbean. As a result, this approach to reducing problematic LCW migration would have a greater impact if supported policies promoting IRM from wealthy countries, including health insurance and pension portability (Coates et al., 2002). For example, if the USA were to extend Medicare coverage for Americans living abroad, then the potential customer base for IRM destinations would be greatly expanded. IRM is a limited solution to the enormous problem of LCW migration. IRM is suitable to a narrow range of countries with the climate and infrastructure to support this industry. To ensure that IRM is beneficial to LCWs and IRM host country populations, this industry must be carefully regulated. IRM is a suitable option for only a subset of aging persons of LCW destination countries, and this subset is limited by destination country policies that do not support insurance and pension portability. That said, in fighting against LCW migration, more policy options are better than fewer and IRM should be taken seriously as an additional and ethically defensible policy option. Private investors will pursue IRM as an economic opportunity regardless of whether it is seen as a tool in combating LCW migration. It is in the best interest of LCWs, their families and their home countries if this development is guided in a way that supports global health equity. Acknowledgements Thanks for feedback on an earlier draft of this article from Johanna Hanefeld and seminar participants at the London School of Hygiene and Tropical Medicine. 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Public Health Ethics – Oxford University Press

Published: Nov 1, 2017

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