Supporting those who sustain us: The role of immigration policies and structural injustice on the health of migrant healthcare workers in medical brain drain

Abstract

The ‘medical brain drain’ phenomenon demonstrates a tension point between the rights of health care workers to move freely, and seek to live and work where they choose, and the needs of the countries which trained them. Often, this extensive, heated, and long running debate focuses on the impacts that medical brain drain has on exit countries, which are often left with inadequate healthcare staffing levels due to the active recruitment of health care workers by destination countries. In this paper, rather than re-examine the extensive debate surrounding the impacts of health worker migration on exit countries, we focus instead on an under theorised aspect of medical brain drain – the injustices perpetrated against migrant health workers in destination countries. Healthcare workers leave their homes for better pay and opportunities but often experience declining health and discrimination. We argue that while destination countries such as the UK are often highly reliant on migrant health care workers, they regularly fail to adequately respond to their needs or address systemic forms of oppression which cause significant harm to those recruited internationally. Our analysis develops a case for more equitable and sustainable approaches to global health workforce planning.

Introduction

The British National Health Service (NHS) has for years endured significant worker shortages, with an estimated shortfall of 15 million workers in 2020. ¹ In response to this ongoing shortfall, the NHS has historically recruited migrant workers, often from low- or middle-income countries, upon whom it is increasingly reliant. ² Migrant workers now make up 20% of the UK workforce, with their share steadily rising in the NHS. ³ Whilst this recruitment represents the response to an immediate requirement to fill workforce gaps, deeper ethical and moral concerns are raised surrounding the consequences for migrant workers, and their countries of origin. Health Worker Migration provides destination countries with a solution to the challenges created by worker shortages significantly more quickly than is possible via increased training of domestic health workers. Despite the growing demand for healthcare professionals, host countries do not train enough ‘regularly resident’ individuals to fulfil the workforce needs. ⁴ To illustrate, within the UK, as of 2023 – approximately 5000 medical training places per year will be needed to offset the need for mass international recruitment and promote workforce sustainability long-term. ⁵ Martineau et al. argue that this may seem to be an intentional attempt to rely on international migration through Medical Brain Drain (MBD), as a cheaper alternative to home-based training. ⁶ MBD, a phenomenon we discuss later in the paper, refers to the migration of health care workers from their origin countries in favour for work abroad often because of pull factors from wealthier regions. ⁷ The cost to recruit internationally trained individuals is often substantially cheaper for host countries, as they do not need to meet the potentially significant training costs of migrant workers. ⁸ This provides host countries with an effective way of recruiting staff to fulfil the workforce and retaining the quality-of-care interactions. However, as discussed in the extensive literature on the ethical implications of the international recruitment of health care workers,^9–12 while international migration provides a solution for workforce shortages and provides opportunities to individual migrant health care workers, it reflects deeper structural injustices within global health systems which often leave residents of exit countries with decreased access to care and disadvantaged health outcomes. ¹³

In this paper, rather than re-examine the extensive debate surrounding the impacts of health worker migration on exit countries, we focus instead on an under theorised aspect of medical brain drain – the injustices perpetrated against migrant health workers in destination countries and the repercussive effects on their health. Healthcare workers leave their homes for better pay and opportunities but often experience declining health and discrimination – an outcome often described as the ‘healthy migrant effect’ (HME). ¹⁴ Thus, while destination countries such as the UK are often highly reliant on migrant health care workers, they regularly fail to adequately respond to their needs, or address systemic forms of oppression which cause significant harm to those recruited internationally. In this paper, we understand structural injustice in the sense developed by Marion Young: Injustice that arises not only from the isolated action of individuals, but from the normal operation of social, political and institutional structures that systematically constrain some groups whilst providing privilege for others. ¹⁵ Structural injustice is therefore diffuse, often unintended, and embedded within policy design and social norms. Framing migrant health worker harms in these terms clarifies why the policies and practices discussed in this paper – although lawful and bureaucratically routine can generate predictable, patterned harms to the migrant's health and well-being. Our analysis develops a case for more equitable and sustainable approaches to global health workforce planning.

Migrant health in medical brain drain

The term Medical Brain Drain (MBD) describes the phenomenon in which qualified health care workers migrate (usually) from resource-limited regions to wealthier countries where their expertise is in high demand, usually for perceived greater financial remuneration, opportunity or quality of life. ⁷ Migration is often framed (and perceived) as mutually beneficial: migrants gain access to greater economic opportunities, while destination countries address their workforce shortages. However, as we argue below, the cumulative impact of systemic injustices and social exclusion imposed upon migrants can undermine or outweigh the benefits they receive. ⁷ However, whilst many workers migrate with the expectation of improved conditions, migrant HCWs are frequently unprepared for, and/or unaware of future systemic injustices and the significant challenges that may arise in their new countries of residence. Public resources, including healthcare facilities, can often be inaccessible or culturally insensitive to these individuals, exacerbating disparities, and ‘othering’ migrants. ¹⁶ In this section, we discuss two key factors which individually and collectively impose wrongful harm on migrants; first, policies, and social practices and attitudes which target migrants for harassment and inflict psychological and material harm. Second, inadequately inclusive health practice and policy, which fails to respond effectively to the specific needs of marginalised and minoritised migrants (and others). Collectively, we argue that these harms impose significant deprivations on migrants, negatively affecting their health and inflicting injustice upon them.

Social and political hostility

First, in 2012 the Conservative British Government established a series of policies intended to create ‘hostile environment’ for ‘illegal migrants’. ¹⁷ These policies focused on creating barriers to participation in daily life for those without legal residency status in the UK. ¹⁷ A range of organisations, including banks, employers and healthcare, social welfare and housing services were mandated to routinely carry out immigration checks and in some cases deny or remove provision of their services to those without the required legal documentation or right to reside. ¹⁸ The 2014 and 2016 Immigration Acts were an instrumental part of these policies and facilitated UK immigration control becoming more socially enforced in everyday life – in effect turning private citizens in a range of professions into de facto agents of state immigration authorities.^19–21 Beyond restricted access to essential everyday services, undocumented migrants were also subjected to direct, public intimidation including the deployment of vans with the slogan ‘Go Home or Face Arrest’ specifically in areas of high migrant populations. ²² While officially intended to encourage voluntary departure, these methods incited fear and reinforced demographic profiling, with evidence suggesting that distrust and anxiety were heightened throughout minoritised communities, regardless of immigration status. ²³ A longitudinal study by Jeffery et al. found that the hostile environment policy imposed serious negative health impacts, including heightened psychological stress on migrants and members of minoritised communities, regardless of immigration status. ²⁴ Although the policy was ostensibly focussed ‘only’ on undocumented migrants (those without formal permission to be in the UK), the harmful impacts of the policy were felt by documented migrants and others of minoritised status even where they were legal residents of the UK. ²⁴

Importantly, the impacts of the hostile environment policy were also felt by migrant healthcare workers, indicating that the relatively privileged position enjoyed by healthcare workers was not enough to protect them from this significant source of government-inflicted harm. These findings can be applied to migrating HCW who, despite not being direct targets of the ‘hostile environment policies or systemic barriers in place may still experience heightened psychological stress and other health effects’. ²⁴ For example, the hostile environment policy has been stipulated to increase the likelihood transmission of communicable disease, such as HIV – as fear of immigration checks and data sharing deters individuals from seeking timely testing or treatment. ²⁵ This avoidance behaviour undermines both individual and public health, as late diagnosis and untreated infection perpetuate transmission within communities. Beyond infectious diseases, the policy has restricted access for survivors of domestic abuse and pregnant individuals, who may delay or avoid medical care for fear of reporting to immigration authorities. ¹⁸ These effects illustrate how coercive immigration control, in the form of the hostile environment policy can transform healthcare spaces into sites of surveillance and exclusion. While migrant HCW with legal residency in the UK were not the target of the hostile environment policy, they still had to navigate a sociopolitical context which was explicitly and deliberately hostile to minoritised people, through the legitimisation of workplace discrimination and racialised exclusion. ²⁶ The shared first-generation migrant experience in a hostile sociopolitical environment coupled with their shared migrant identity and exposure to racial discrimination can create distinct stressors that contribute to poorer health outcomes not seen in native counterparts reinforcing structural inequalities.^24,27 Government policy has also been found to have a significant negative impact on the life expectancy of racially minoritised people, in part because of their reduced access to important social determinants of health.^28,29

Cultural insensitivity in health care

Second, while policies such as the hostile environment do inflict harm on migrants with legal rights to live in their country of residence, they do not officially prohibit access to many important health services. However, despite their official entitlement to health care services, migrant workers often face additional barriers to the enjoyment of that entitlement. For example, the UK charges migrants an additional health surcharge not levied against citizens. ³⁰ Though intended to ensure a ‘fair contribution’ to the cost of health care, the rising cost of the NHS surcharge has caused fear and confusion, leading to the unintended exclusion of migrant HCW from accessing needed care – despite HCW remaining exempt from the policy. ³¹ Bianchi and Saab argue migrants may be triggered into self-defence and seek out other mechanisms to help themselves away from traditional routes when policies create fear. ³² Migrants may then self-exclude or late present to services resulting in detrimental impacts on their health and perpetuating the Healthy Migrant Effect (HME). ³³ This self-exclusion is not explicitly the result of exclusionary rules but arises due to the cumulative impact of policy targeting and misinformation. As a consequence of policies like the hostile environment, migrant HCWs can face exclusion from accessing care if they are led/come to believe that they are ineligible or not fully entitled to NHS services. ³⁴ Correlatively, a Doctors of World study showed that 22% of migrants with exemption status had been incorrectly charged for healthcare, with some delaying or avoiding care as a result of fear. ³⁵ Migrant HCWs can still be vulnerable to this form of harm despite knowledge of the healthcare system, as amongst HCW understanding of the charging system is still not optimised, further perpetuating harm and exclusion. ³⁴

The harms inflicted by such exclusion are exacerbated by the fact that in many cases the health care systems of destination countries are often inadequately sensitive to the particular health needs and cultural background of migrants, regardless of profession. ³⁶ This insensitivity refers to an institutional inability to recognise or incorporate the lived experiences, differing demographic profiles or cultural needs of migrants within care provision.^36–38 Historically, migrant populations have been underserved in health policies and research, their data and information is not synthesised in data analysis. ³⁹ This has led to lack of acknowledgement of their diversity, leading to both covert and overt harms – for example in forms of microaggressions or systemic failures in understanding risk factors which placed migrant populations in areas of deprivation at higher risk of death than their native counterparts in the UK COVID-19 pandemic.^40,41 Lack of diversity and omission of minority groups from research samples often stem from distrust and difficulty to recruit diverse participants due to unethical practices in previous research, such as the UK Infected Blood Scandal.^42,43 Examples of cases affecting UK migrant groups include unevidenced claims in 1958 that penicillin is ineffective in treating ‘venereal disease’ in migrant populations and the 1964 forced x-ray investigations for migrants at Heathrow to check for infectious disease dubbed the ‘final step to become an Englishman’.^44–46 Although these practices occurred decades ago, the failure of new research to adequately include minority groups fortify discriminatory legacies.^41,42,47 More recently, stereotypes about race, and a lack of training in various medical disciplines can affect treatment, leading to significantly worse outcomes for non-white patients. ⁴⁸ This illustrates Silva's ‘racism without racists’ framework, which states that consistent racist actions can become naturalised and normalised through repetition by society to become covert institutionalised racism. ⁴⁹ This framework can be applied to migrant HCWs where health information does not incorporate enough minority groups as structural exclusion has become normalised, producing ongoing institutional racism even without overt intent through not address the sample gap.^49–51

Ultimately, migrant HCWs face a ‘systematic threat’ to their health through exclusion from research, this exclusion severs the foundation required equitable and fair service prioritisation and implementation. ⁵² This failure can impose direct harm through delays in recognition and diagnosis of health conditions in migrant populations, constraining viable treatment options.^52–54 The Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE) 2023 and 24 Report details how women from minority groups, particularly those from the global south are statistically four times more likely to die in the perinatal period with higher rate of morbidity in 2019–21 in those who were born outside of the UK, a figure reported to be underestimated.^54,55 These women were found to have a statistically higher rate of mortality than native counterparts.^54,55 Contributing factors included vaccine hesitancy and the absence of clear research which explicitly addressed the risks and benefits of medical interventions for ethnic minority women, such as impacts of vaccines. ⁵⁵ Similarly, migrants living in the UK for more than a decade are more likely to have a cardiac or metabolic long-standing health condition than their native counterparts. ⁵⁶ This exclusionary dynamic present in scientific research extends beyond socio-economic determinants and therefore experienced HCW's or long-term migrant residents remain vulnerable to adverse health outcomes or premature death – due to systematic exclusion from research. ⁵⁵ The systemic exclusion of migrants due to lack of incorporation of diverse populations within samples thus creates significant inequities in healthcare outcomes. If left unchallenged, it leads to migrant HCWs receiving care within a system that reinforces disparities in diagnosis and treatment, whilst simultaneously relying on their labour to sustain delivery.

Discussion

Migrants, often, have better health outcomes than equivalent counterparts in host and origin countries upon relocation.^57,58 This advantage is shaped by selective migration systems that favour younger, healthier and more educated individuals.^59,60 However, this health advantage is rarely sustained and over-time – migrant health deteriorates often at a faster rate than seen in other groups due to systemic and structural harms embedded in the systems that disproportionately benefit and are reliant on migrant labour.^14,60,61 This occurrence is known as the ‘Healthy Migrant Effect’ (HME) and commonly affects all migrants, including migrant HCW, regardless of documentation status. ⁵⁸

This paper has identified three key mechanisms through which migrant HCW are subjected to harm. First, they must navigate hostile environments shaped by immigration policy and structural racism, which often leads to self-exclusion from healthcare – even amongst legally resident healthcare-workers. Second, when care is accessible, it often lacks the inclusivity to meet their needs. Systemic failures to build trust recognise cultural contexts and develop inclusive health literature and training contributes to ongoing inequity, including misdiagnosis and failure to recognise potentially significant symptoms. Third, these factors collectively drive the depletion of migrant health – transforming the initial promises of migrations into a slow, systematic erosion of wellbeing.

The injustices faced by migrant HCWs reflect deep-rooted disparities within global healthcare systems. While migration allows the global north to benefit from a steady influx of migrant health workers at peak productivity, it simultaneously worsens inequities in the global south and lacks inclusive infrastructure required to sustain these workers in return (39–42). In addition to the highly documented harms inflicted upon exit countries, health worker migration can also inflict significant injustice on migrants themselves, in the form of oppression, exclusion, and harms to health experienced in their new country of residence. The cumulative effect of these harms is under-theorised, but they undermine the wellbeing of migrant HCWs and contribute to the depletion of migrant health and expose migrant HCW to systematic disadvantages that ultimately lead to poorer health than those they work alongside (78).

As we have argued, the impact of migration and residency in (only superficially welcoming) destination countries for migrants should not be ignored. While migration does often generate at least some benefits for migrant health care workers, in many cases, these benefits are accompanied by significant harm. In and of themselves, these harms may be felt to be outweighed by the noted benefits but given the dependency of many destination countries on migrant health workers, they still constitute a form of exploitative injustice perpetrated against those workers. Put differently, even where the benefits of migration are perceived by migrants to outweigh the harms they endure, it is at best questionable whether they do so to a sufficient degree so as to avoid qualifying as wrongful harm. Destination countries therefore hold moral responsibility for the consequences of their recruitment practices and must act accordingly. They must acknowledge their responsibility – not only to fill workforce shortages, but to ensure the people filling these gaps are protected from systemic exploitation. This means rejecting hostile policies, embedding cultural competence in care delivery and investing in long-term strategies that prioritise inclusion, equity and health injustice.

This paper does not deny injustice occurs towards other migrant workers; rather it identifies migrant healthcare workers as a paradigmatic case in which dependence generated by the UK healthcare system along with institutional pull factors intensifies moral responsibility. Migrant healthcare workers occupy a morally distinct position – unlike most migrant groups, they are actively recruited or attracted by destination countries to sustain essential public health systems. This recruitment clarifies responsibility: the harms experienced by migrant healthcare workers are not merely incidental consequences of migration regimes but arise within systems that knowingly rely on their labour. While similar structural injustices may affect other migrant labour sectors, the centrality of healthcare to collective wellbeing and support, coupled by deliberate reliance on internationally trained clinicians make failures to safeguard migrant healthcare workers morally distinctive.

Unlike overt forms of injustice, structural injustice affecting migrants HCW results in harm that is difficult to identify or determine a single causative factor, due to its embedded nature in broader social and political structures. ¹⁵ The analysis presented here demonstrates that immigration policy, healthcare charging regimes and culturally exclusionary clinical systems function collectively as structural mechanisms of harm, thereby meeting the theoretical criteria for structural injustice as opposed to incidental inequality. This paper cannot capture every complexity of this issue. However, it underlines a central claim: to support migrant HCWs meaningfully, we must move beyond reliance on their labour and towards a commitment to dismantling the systemic harms that erode their health, wellbeing and the chances of professional growth.