This report builds on OECD work since 2007 to monitor trends in the migration of health workers to promote more informed policy dialogues between source and destination countries of doctors, nurses and other categories of health workers. The report is divided in two parts and seven chapters.

This report describes how the international migration of doctors, nurses, and medical students in OECD countries has evolved over the past decade. These recent trends are examined in the context of larger migration patterns, including the increasing mobility of students and highly skilled workers in general. This work contributes to the call for regular monitoring of migration flows in the 2010 Global Code of Practice on the International Recruitment of Health Personnel.

This chapter reviews the contribution of foreign-born and foreign-trained doctors and nurses to the rising number of doctors and nurses working in OECD countries over the past decade. The number of foreign-trained doctors working in OECD countries increased by 50% between 2006 and 2016 (to reach nearly 500 000 in 2016), while the number of foreign-trained nurses increased by 20% over the five-year period from 2011 to 2016 (to reach nearly 550 000). The United States is still the main country of destination of foreign-trained doctors and nurses, followed by the United Kingdom and Germany. The number of foreign-trained doctors has also increased rapidly over the past decade in some European countries like Ireland, France, Switzerland, Norway and Sweden. However, it is important to bear in mind that not all foreign-trained doctors are foreigners as a large number in countries such as Norway, Sweden and the United States are people born in the country who obtained their first medical degree abroad before coming back. In these cases, it is not appropriate to refer to this phenomenon as a “brain drain”, particularly as these people usually pay the full cost of their education while studying abroad.

The number of international students pursuing medical education away from their home country has increased significantly over the past decade, with some countries becoming popular destinations. For example, around half of all medical students in Ireland, nearly a third in Romania and a quarter in Poland are international students. This mobility of students is driven by demand and supply factors, including admission limits in medicine in the home countries of these students and active recruitment strategies of some medical schools. The mobility has been supported by the mutual recognition of qualifications, particularly across EU member states. Most international students from OECD countries studying medicine abroad intend to return to their home country to complete their postgraduate training and work as doctors. While most students from countries like Israel, Norway, Sweden, and France are able to do this, this is not the case for many students from countries like Canada or the United States who are facing a bottleneck when they wish to return to their home country, as the number of training/residency posts is significantly lower than the number of applicants. This raises the risks of a waste in human capital if these new international medical graduates are not able to complete their training.

Historically, many foreign students have come to France to study medicine. In 2017-18, around 12 000 foreign students were enrolled in French medical schools, a lower number than in 2010-11. Increasingly, these international students come from European countries with the number coming from other parts of the world decreasing. A growing number of French students also go to other European countries to get at least a first medical degree, before returning to France to complete their postgraduate training (internship). It is difficult to find precise figures on the number of French students studying medicine abroad, but it has gone up, particularly in Romania, where it increased from around 680 in 2014-15 to over 1 200 in 2017-18. Most French students who study abroad do so either because they have failed the numerus clausus exam to get into a medical education programme in France or because they consider the risk of failing this exam too high. The recent government proposal to increase both the number of students admitted to medical education in France and the flexibility of the admission process may bring down the number of French students going to study abroad.

Ireland has the highest number of medical graduates per population among OECD countries, but half of the students come from other countries. The number of international students is not subject to the numerus clausus policy that limits the entry of Irish students into medical education, and the medical schools have become increasingly dependent on the tuition fees international students pay. However, the large student numbers are not matched by opportunities to complete an internship and postgraduate training. To the contrary, the number of internship places for international medical students has fallen as national authorities reserve a greater proportion for the growing number of Irish medical graduates to ensure a good return on the public investment in their education. Thus, most international students try to complete their medical education and enter postgraduate training outside Ireland. Also, many Irish medical graduates and (newly trained) doctors seek training and job opportunities abroad. Hence, while Ireland provides initial medical education to a large number of students, since many leave the country after graduation, it nonetheless relies heavily on international recruitment of doctors to fill its domestic needs. More coherent education, training, and employment policies are needed to address this paradox.

Since 1993, most Polish medical schools have opened full-cycle study programmes in English for international students seeking education outside their home country either due to high tuition fees or limits on student intake. The schools continually adapt their international offer and promote recognition of their degrees also outside the European Union. Initially, the schools attracted students mainly from the United States; later also from Middle Eastern and South-East Asian countries; more recently from Norway, Sweden and Canada, and increasingly also from India. International students bring additional income for the schools; this helps to increase the attractiveness of faculty jobs, thereby addressing the emigration of medical educators from Poland. Simultaneously, meeting the domestic demand for medical graduates has been prioritised by the government: the capacity in Polish programmes has increased much more rapidly than in the English programmes. While the number of domestic medical graduates has increased, the emigration of Polish doctors is a concern.

For international medical students, the attractiveness of Romanian medical schools has increased since the country’s accession to the European Union in 2007, as they offer diplomas with EU-wide recognition for relatively low tuition fees and living costs. At present, nearly all medical schools offer programmes in English and/or French, taking up around 30% of the total teaching capacity. The internationalisation of medical education in Romania has taken place in the absence of any formal national strategy. Rather, medical schools have developed their own strategies to attract international students as a way to generate additional income, to be able to recruit and retain academic staff and to develop their infrastructure. Although Romania has become increasingly attractive for international medical students, owing to poor working conditions and relatively low salaries, the country’s health system is not attractive as a workplace, and most international medical graduates leave after obtaining their first degree.

This chapter documents changes from 2006 to 2016 in the number of physicians, registered nurses (RNs) and practical nurses (PNs) in Canada. It identifies those working in each occupation as well as those reporting relevant educational credentials but not working in the occupation. The number of practicing physicians and PNs grew at double the rate of the total workforce, whereas practicing RNs only grew at one-third that rate. The high physician growth rate was a result of education and immigration policies intended to address perceptions of increasing physician shortages. In contrast, the low RN and high PN growth rates likely reflect a shift to lower cost PNs with no growth in total nursing relative to the workforce. The growth rate of foreign-born, foreign-trained professionals working in all three professions was larger than the relevant occupation’s average growth rate. Despite this, the percentage of foreign-born, foreign-trained individuals not working in their trained profession also increased for physicians and RNs. The net effect is that the percentage of foreign-born, foreign-trained potential physicians and RNs working in their profession declined. This “brain waste” reflects mismatches between health and immigration policies.