Report No. 48988-LAC The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Options for Reform June 2009 Human Development Department Caribbean Country Management Unit Latin America and the Caribbean Region Document of the World Bank The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform LABOR EDUCATION THE NURSE AND MARKETS IN THE ENGLISH-SPEAKING CANCOM: ISSUES AND OPTIONS FOR &FORM Human Development Department Caribbean Country Management Unit Latin America and the Caribbean Region June 2009 CONTENT A. EXECUTIVE SUMMARY .................................................................................................................... 1 B. INTRODUCTION.................................................................................................................................. 6 C. RESEARCH APPROACHES ............................................................................................................... 8 D. THE CARICOM .................................................................................................................................. 11 E. THE ES CARICOM NURSE LABOR MARKET ............................................................................ 15 Active Supply o f Nurses ........................................................................................................................ 15 Demand for Nurses .............. .......................................................................... 16 Inactive Supply o f Nurses .... ............................................................................................... 18 Intra-regional Dynamics............. ............................................ ............................... ......... 19 Increments and Attrition ........................................................................................................................ 19 F. INTERACTIONS BETWEEN THE ES CARICOM AND THE GLOBAL NURSE LABOR MARKETS ........................................................................................................................................... 20 Stocks o f Caribbean-Trained Nurses in Prime Destination Countries ....................................... .20 Trends o f Migratory Outflows .................................................... Factors Determining the Migration Decision Inflows ................. .................................................................. G. The ES CARICOM Nurse Education Market ................................................................................. ..29 ....................................... ...................................................................................................................... 31 ......... Ongoing and Planned Reforms .............................................................................................................. 33 H. A REGIONAL NURSE LABOR MARKET OUTLOOK ................................................................ 35 Future Demand and Supply under Current Policies .............................................................................. .35 Future Supply, Demand and Shortages under Alternative Policy Scenarios..... Costs and Financing Solutions for an Expansion and Strengthening o f Trainin ................... 40 Impact o f Full Implementation of CSME on Intra-regional Migration Flows ...... I. CONCLUSIONS AND RECOMMENDATIONS ............................................................................. 44 Challenges.............................................................................................................................................. 44 Entry Points to Stabilize Supply ....... ................. 45 Current Efforts ....................................................................................................................................... 46 Policy Options to Reduce Shortages ........ ................... Financing the Strengthening and Scaling- ........................................................... 50 Recommendations............... .. 11 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform TABLES Table 1: Main Research Activiti Table 2: Profiles o f CARICOM s ............................................... Table 3: CSME Modes o f Free Movement o f Services ................................................. 13 Table 4: Employment Status ofNurses in Jamaica ............. Table 5: Residency o f Jamaican-trainedNurses for Cohorts o f Nurse Student Graduates..... Table 6: Class Rank o f Nurses, by Non-Migrant and Migrant R N s , RNs Interviewed (1 980 ............................................................................................. Table 7: Rational for Emigration, RNs Interviewed and Ever Lived Abroad ................ Table 8: Satisfaction with Salary, by Country o f Residence, RNs Interviewed Table 9 : Satisfaction with Salary Before Table 10: Rational for Emigration, R N s I ...................27 Table 15: Proportion o f Student Paying for Tuition i Table 16: Key Nurse Education Demand-side Indic Table 17: Examples o f Nurse Education ............................... Table 18: Description o f Scenarios for S Table 19: Willingness to Pay for Nurse Training Education among Jamaica-trained nurses [US$, 20071.38 Table 20: Costs and Benefits and to Whom They Would Accrue from One Nurse Being Trained in Jamaica [in US$ 1,000, 20051 ................................... ..42 Table 21: Principle Policy Options to Manage Migration ................. ................................................. 48 FIGURES Figure 1: N u r s e Shortages in Case Study Countries .............. ..... ... 17 Figure 2: Nurse per 1,000 population vs. GDP per Capita ............. ................................................. 18 Figure 3: Flows o f ES CARICOM traine Figure 4: Flow Rates in Relation to GDP . ................ Figure 5 : Flow Rates in Relation Figure 6: U S NCLEX Pass Rates Figure 7: Supply and Demand for Nurses in the ES Speaking CARICOM Under Current Policies .........$ 35 Figure 8: Composite Projection of Supply and Demand in the Nurses Labor Market of ES CARICOM Countries in 2007-2025. Figure 9 : Projection of Supply Figure 10: Cost o f Improving an Figure 11: Hourly Salaries and GDP per Capita across Selected ES CARlCOM Countries ...... Figure 12: Key Education Market Indicators SUPPLEMENT: ANNEXES Annex A: Statistical Data Annex B : Methodology Annex C: ES CARICOM Case Country Studies Annex D: OECD Case Country Studies Annex E: Jamaican Nurse Labor Survey REFERENCES ... 111 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform ACKNOWLEDGEMENTS This report has been prepared by a team including Christoph Kurowski (Task Team Leader), Yuki Murakami, Tomoko Ono, Luke Shors, Marko Vujicic and Afsaneh Zolfaghari. It draws on research contributions from James McDonald Buchan, Shampa Audrey Corry, Donna Muirhead, Oscar Ocho, Pauline Reid, Ann C. D e Roche and Elizabeth Ward. Editorial support was provided by Imran Mujawar and Fiona Mckintosh, logistical and document processing support by Mary Dowling, Veronica Jarrin and Judith Williams. The work was carried out under the general direction o f Chingboon Lee, David Warren, Keith Hansen, Evangeline Javier, Carolyn Anstey and Yvonne Tsikata. The peer reviewers were Caglar Ozden, Magdalena Manzo, Amit Dar and Gillian Barclay (Pan American Health Organization). Additional comments were received from Mary Mulusa, Shiyan Chao and Amparo Gordillo-Tobar. The study design benefitted from consultation with Ministers o f Health, their teams and nurses associations from Barbados, Guyana, Jamaica, St. Lucia, St. Vincent & the Grenadines, and Trinidad & Tobago as well as with staff from the Pan American Health Organization. The report benefitted from comments on an early draft by the Caribbean Regional Nurse Council through the Secretariat o f the Council o f Human and Social Development o f CARICOM and a review o f i t s messages in a public panel discussion with Fitzhugh Mullan (George Washington University) and Patricia Pittman (AcademyHealth and Johns Hopkins School o f Advanced International Studies) held at the World Bank offices in April 2009. iv The Nurse Labor and Education Markets in the English-Speaking CARICOM. Issues and Optionsfor Reform A. SUMMARY EXECUTIVE 1. The present report concludes the second phase o f the cooperation between C A R I C O M countries and the World Bank to build skills for a competitive regional economy. It focuses on the nurse labor and education markets o f the English-speaking CARICOM. The topic was suggested by Ministers o f Health concerned with chronic staffing shortages in local health facilities and anecdotal evidence o f high migratory outflows. The chronic staff shortages are likely to hamper the quality and efficiency o f health services, both o f which are critical factors in attracting international businesses and retirement locales. The rationale for focusing o n nurses was that they compose the largest group o f health care professionals in the ES C A R I C O M and play a critical role in strengthening health services in the face o f the demographic and epidemiological transition in the region. Moreover, major achievements in improving and harmonizing curricula, degrees, and licensing procedures among the English-speaking countries o f C A R I C O M facilitate the international competition for this globally scarce human resource. 2. The chief objective o f this second research phase was to produce a comprehensive assessment o f the nurse labor and education markets o f the ES CARICOM. Despite major research efforts, data limitations remained a significant problem. However, information gathered was sufficiently robust and complete to provide for the first time a comprehensive picture. As we elaborate in this report, it shows a highly fragile supply- side equilibrium that will be increasingly insufficient to meet local demand. 3. We estimated that approximately 7,800 nurses constituted the active supply in the region. This translates into a nurse per 1,000 population ratio o f 1.25 with roughly 1 nurse per 1,000 population directly providing care. These levels compare unfavorably to those in OECD countries where ratios tended to be 10 times higher. Over 90 percent o f all nurses practicing in the ES C A R I C O M were employed in the public sector. Less than 10 percent o f were providing primary care; a level which i s likely insufficient to effectively respond to the health challenges associated with the demographic and epidemiological transitions occurring in the English-speaking CARICOM. 4. The demand for nurses exceeded supply in the region with approximately 30 percent o f all approved positions vacant. Vacancy rates may understate the true needs o f poorer countries in the region. They were calculated based o n approved positions in the public sector for which there i s funding and are, thus, subject to budgetary constraints. Furthermore, based on our analysis, it did not appear possible to fill these vacant positions by mobilizing trained nurses who were inactive as rates o f participation in the labor market were extremely high. 5. Annual attrition rates were about 8 percent with outmigration the main source. Canada, the UK, and the U S represented the primary destination countries. We estimated that the number o f English-speaking CARICOM-trained nurses working abroad was roughly three times the number working in the English-speaking CARICOM. To our knowledge, this ratio o f health migrants compared to the locally remaining stock i s without parallel in the world. Our analysis also showed that current rates o f emigration appeared to be lower than in the past. Furthermore, we found that individual countries' 1 The Nurse Labor und Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform were not substantially impacted by intra-regional migration, but this may change with the full implementation o f the Caribbean Single Market Economy. 6. Emigration appeared not only to cause significant shortages o f nurses in the region, but the brightest nurses were the ones leaving to work abroad. Our research suggests migratory flows were primarily driven by wage differentials, network effects, and worker dissatisfaction at home. 7. We identified 43 pre-service (general nursing) programs producing slightly less than 600 graduates per year. Combined with recent initiatives to recruit nurses from abroad, this translated into a net increment rate o f approximately 10.5 percent. With the increment rate slightly above the attrition rate, the supply-side equilibrium was insufficient to fill existing vacancies in the short, medium and long-term. 8. In the case study countries, we observed three types o f nursing schools with different levels o f autonomy as well as sources o f funding; public, semi-autonomous, and private schools. Nurse education programs in the region tended to be publicly provided. In addition, governments co-financed autonomous and private nursing schools. However, we observed an early trend towards co-payments by students. Information from a survey o f Jamaican nurses showed that there was an increase in the proportion o f students paying for their own tuition. Publicly financed and provided nurse education as well as publicly financed and provided health care appeared to preclude private providers offering nurse training programs despite high levels o f unmet demand. 9. Our data suggested that the number o f annual graduates was highly constrained by l o w completion rates. We estimated that o n average only approximately half o f the students in the case study countries completed their studies. These l o w pass rates raised concerns about the quality o f education. 10. Our analysis indicated that there was an insufficient number o f nurse tutors. This shortage i s likely to be the major constraint to expand and strengthen nurse training capacity in the region. We estimated that the student to tutor ratio was 30:l. Given the need for tutors with specialized training skills and the need for providing personal attention to students through active-learning methodologies, it was likely that this ratio was too high to achieve high quality levels. 1 1. Our analysis did not identify any demand-side constraints to significantly scale-up nurse training in the English-speaking CARICOM. I t showed that between the years 2004-2006, there were o n average three qualified candidates competing for every position in nurse training programs. 12. All countries in the region have taken significant steps to increase the quantity and quality o f nurse graduates. In 2006, an estimated 1,000 nursing students graduated in the five case study countries, a record high during the period we examined. In addition, efforts were made to improve curricula and pedagogical approaches as well as to harmonize nurse education programs. 13. Nonetheless, we estimated that under current policies, with the notable exception o f training as the exclusive source o f increments in line with the principle o f self- sufficiency, the gap between demand for and supply o f nurses will widen from 3,400 nurses today to 10,700 nurses in 2025. Given this predicament, we examined the impact 2 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform o f different policy action o n future shortages focusing o n supply-side interventions. Specifically, we investigated the feasibility and impact o f expanding training capacity and improving completion rates. Both approaches seemed generally feasible. However, they would require a substantial increase in the number o f nurse tutors. In the short-term, this potential constraint could likely be relaxed through a variety o f innovative measures such as promoting one-year online courses for nurse tutor education or by importing nurse tutors through bilateral arrangements with high capacity countries. 14. Maximizing the completion rate and increasing intake by 50 percent would result in a 230 percent increase in the annual number o f nurse graduates, which would translate to an increase o f 2,200 nurses by 2015 and 6,200 by 2025. Maximizing the completion rate and increasing intake by 100 percent would result in a more than three-fold increase in the number o f nurse graduates, which would translate to an increase o f 3,100 nurses by 2015 and 9,600 by 2025. Even though this second, more aggressive scenario would result in increments into the labor market significantly exceeding attrition, these efforts would s t i l l be insufficient to meet the demand for nurses in the region by 2025. In fact, with the exception o f St. Vincent and the Grenadines, no country would meet i t s demand for nurses. We estimated that the costs o f expanding training capacity and improving completion rates between 2009 and 2020 would total between U S $ 17 and US$ 31 m i l l i o n depending on the scenario. 15. With the current high migration and high subsidization levels, benefits accrue to the student and economies abroad, while increased costs are exclusively born by the English-speaking C A R I C O M governments. Nurse training in the English-speaking C A R I C O M could be financed under a model that more fairly assigns costs to those who benefit. Our analysis showed a pattern o f costs and benefits that suggest a tripartite financing model o f nurse training, including contributions from students, local, and foreign governments. 16. Current shortages could easily be exacerbated as the fragile supply-side equilibrium erodes. As factors controlling attrition are primarily beyond the control o f local governments, changes in the external environment could quickly destabilize this delicate balance. Relaxed entry regulations in destination countries outside the region may lead migration to return to or exceed historic levels. In addition, with the full implementation o f the CSME, increased levels o f intra-regional migration along socio- economic and wages gradients are likely, threatening the fragile supply-side equilibrium in some o f the ES C A R I C O M countries. 17. Compounding this potential o f increased emigration, our survey data showed that high levels o f dissatisfaction existed among nurses in the region. In addition, our survey suggested that a major impediment to emigration was the lack o f knowledge about migration logistics and work opportunities. Outflows and in turn nurse shortages would worsen as non-migrants who have considered the possibility o f emigrating become more informed about their options. 18. If the English-speaking C A R I C O M i s to address current and future nurse shortages, be increasingly protected against a large outflow o f nurses, and simultaneously recognize an individual's right to freedom o f movement and right to access health services, then various policies must be examined. The most important policies include (i) 3 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform increasing completion rates; (ii) increasing nurse training capacity through increasing the number o f nurse tutors; (iii) managing migration; (iv) mobilizing the inactive supply; and (v) improving the allocation o f existing human capital must all be explored. Focusing o n strategies (i), and (iii) critical as they represent the biggest areas o f current losses. (ii), are 19. In the short term, we believe that addressing completion rates may be the best entry point to bolster the workforce in the region. With only an average o f 55 percent o f students graduating in the region, drop-outs represent a tremendous loss o f potential human resources. Because many schools in the region have substantially higher completion rates, we believe that region-wide improvements in completion rates are possible. Strategies, such as establishing national monitoring systems o n retention, increasing the flexibility o f the curriculum to accommodate different schedules and interests, creating smaller learning groups and identifying peer mentors have all been shown to improve retention o f students. 20. In the medium term, increasing nurse training capacities appears to be the most viable option to meet the demand for nurses in the English-speaking CARICOM. Our analysis showed that unlike other regions in the world, the capacity o f the education system i s not a binding constraint to scaling up the number o f nurses. Infrastructure constraints can be relaxed with additional financing. Clinical opportunities exist in substantial excess o f what i s being utilized for training. However, creative strategies need to be used to address the insufficient number o f nurse tutors. English-speaking C A R I C O M countries should consider promoting policies, many o f which can be developed under the Global Agreement on Trade in Services, such as (i) training nurse tutors outside the region; (ii)using in-service programs offered on-line; (iii)allowing for the temporary recruitment o f nurse tutors from Canada, the UK and the US; and (iv) drawing on the Diaspora to meet the needs for tutors with specific clinical skills and areas o f expertise. 21. Managed migration policies attempt to reconcile two human rights - the right to freedom o f movement and the right to access to health services. Because these rights may be at odds, practical implementation o f these ideas has in general been difficult, technically as well as politically. Globally, well-documented and evaluated systemic approaches are scarce. Regionally, a managed migration program emerged just recently and gathered support from several stakeholders. However, upon a recent review, initiatives remained largely driven by individual countries or individual organizations with little impact to date. However, the threat imposed by the growing demand for nurses in prime destination countries o n the current fragile supply-side equilibrium in the English-speaking C A R I C O M warrants that all policy options be carefully revisited and explored. 22. As noted earlier, all case study countries were engaged in activities and/or had plans to improve the quality o f nurse education and increase the number o f nurses trained. Consultations with individual countries should take place to assess these plans. In the course o f our research, we learned that monitoring and evaluation data o f the nurse labor and education markets were scarce. Given the potential fragility o f the ES C A R I C O M nurse labor market, i t i s critical that countries more closely monitor nurse labor market (e.g. vacancy levels, skill-mix, and attrition including migration) and nurse education market (e.g. student to tutor ratios, intake rates, and completion rates). 4 The Nurse Labor and Education Markets in the English-Speaking CARICOM. Issues and Optionsfor Reform 23. Ultimately, we believe that a false dichotomy exists between choosing to focus on increasing nurse training capacity versus focusing o n managing migration; in fact, both must be done jointly and immediately. If the ES C A R I C O M i s to address current and future nurse shortages, be increasingly protected against a large outflow o f nurses and simultaneously recognize an individual's right to freedom o f movement, the ES C A R I C O M must both increase the number o f nurse graduates and manage migration. 24. A regional effort to strengthen and scale-up nurse training i s critical to success. The scarcity o f tutors, the intra-regional distribution o f health care capacity and the limited number o f institutions offering higher degrees warrant regional coordination. Ideally, country initiatives would be collated into a single, regional strategy. Moreover, the implementation o f the CSME and associated increases in intra-regional migration requires a coordinated approach to govern the nurse education and labor markets. 25. Managing migrations requires reaching out to destination countries, the goal being to establish and agree o n annual flows, cost-sharing arrangements for necessary investment in nurse training capacity and technical support. Such agreements would be in the best interests o f both source and destination countries, as they make flows more transparent and predictable and facilitate workforce monitoring and planning o n both ends. I t would help destination countries that struggle to achieve self-sufficiency in reconciling immigration policies with foreign policies. However, as for efforts to strengthen and scale-up training capacity, only a regional initiative i s likely to succeed. Given the discrepancies between the sizes o f workforces in the ES C A R I C O M vis-a-vis Canada, the UK, and the US, only a joined approach o f ES C A R I C O M countries would create a win-win situation. More recent experiences o f attempts to manage migration suggest that small scale initiatives do not sustain the interest o f destination countries (Dawson 2006). 26. Efforts to strengthen and scale-up training capacity and manage migration should be combined with financing reforms that more fairly assign costs to those who benefit. A tripartite financing model appeared to be most appropriate with contributions from governments in the ES CARICOM, from governments in destination countries and students themselves. 27. Collectively, the discussed actions have the potential to stabilize the delicate demand and supply equilibrium o f nurses in the ES CARICOM. Swift corrective measures are o f utmost importance. 5 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform B. INTRODUCTION 28. Over the past decade, the Caribbean Community (CARICOM) has made significant achievements in advancing economic and political integration. C A R I C O M member countries have taken steps t o harmonize economic, monetary, and fiscal policies as well as legislation and standards in various sectors. For example, in health and education, efforts have been made to establish common equivalency standards and accreditation systems (e.g. the accreditation for education in medical and other health professions). They created and implement the C A R I C O M Single Market and Economy (CSME) that includes, among other objectives, free trade in goods, services, capital, and skills (CARICOM 2008). 29. T o fully realize the potential of regional integration, CARICOM countries and the World Bank have worked together to build skills and increase the community's competitiveness. The common market promises to boost private investment. Effectively competing for these investments, however, hinges o n the availability o f skilled labor. Historically, the region has invested greatly into the education o f i t s citizens. Literacy levels are among the highest in the world. Access to education i s free, including by and large the tertiary level. Despite these efforts and achievements, previous analyses suggest that the shortage o f skilled workers increasingly hampers the community's competitiveness. Therefore, C A R I C I O M countries and the World Bank agreed to investigate h o w to meet the demand for skilled labor. The results o f the first phase o f this collaboration are detailed in the report "School and Work in the Eastern Caribbean: Does the Education System Adequately Prepare Youth for the Global Economy" (Blom & Hobbs 2008). The report concludes that the education system requires significant strengthening to assure that young people are adequately prepared for jobs required in the global, high-technology economy. 30. The present report concludes the second phase o f the cooperation between CARICOM countries and the World Bank to build s k i l l s for a competitive, regional economy. I t focuses on nurses in the English-speaking (ES)* CARICOM. The topic o f this second phase was suggested by Ministers o f Health concerned with chronic staff shortages in local health facilities and anecdotal evidence o f significant migratory outflows. The chronic staff shortages are likely to hamper the quality and efficiency o f health services, both o f which are a critical factor in attracting international businesses and retirement locales. Analyses focus on nurses who compose the largest group o f health care professionals in the C A R I C O M and play a critical role in strengthening health services in the face o f the demographic and epidemiological transition in the region. Furthermore, major achievements in improving and harmonizing curricula, degrees and licensing procedures among the ES C A R I C O M countries facilitate the international competition for this globally scarce human resource. This report complements work carried out by C A R I C O M countries in collaboration with the Pan American Health Organization to understand the regional labor market o f physicians. ' From here on, we will refer to the English-speaking CARICOM as ES CARICOM 6 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform 31. This report provides for the first time a comprehensive picture o f the ES CARICOM nurse labor market and demonstrates a highly fragile supply-side equilibrium insufficient to meet local demand. Efforts by ES C A R I C O M countries have begun to shed light o n the national and regional nurse labor markets. These efforts are particularly important as the transition to a fully implemented C S M E as well as the nurse shortages facing high-income countries necessitated a greater understanding o f the national, regional, and the global nurse labor market. Thus far, they included research to better understand the linkages between the nurse labor and nurse education markets. Yet, findings remained inconclusive as data were scarce and o f limited quality. Therefore, the chief objective o f this study was to fill critical information gaps and produce a comprehensive assessment o f the regional nurse labor market. As we discuss in this report, despite major research efforts, data limitations remained a problem. However, information gathered was sufficiently robust and complete to provide a comprehensive picture o f the ES C A R I C O M nurse labor and education markets. As we elaborate in this report, the key feature o f the ES C A R I C O M nurse labor market i s a highly fragile supply- side equilibrium that i s insufficient to meet local demand. 32. The report has the following structure: Subsequent to this introduction, the report provides an overview o f the studies and corresponding research approaches that constitute the basis for this report. For the reader not familiar with the CARICOM, section D provides background information including general labor market trends. Section E analyzes the current local and regional nurse labor markets. A section follows that examines the interaction between the regional and the global nurse labor market. Section G then describes the ES C A R I C O M nurse education market. Section H presents projections for the nurse labor market and section Idiscusses issues and possible policy responses. 33. The report i s complemented by a supplement. This supplement provides detailed descriptions o f (i) research methods; (ii) data used to produce graphs and all the figures in this report; (iii) finding o f country case studies in the ES CARICOM; (iv) the the findings o f country case studies in Canada, the United Kingdom (UK) and the United States (US); and, (v) results o f a survey among Jamaican nursing school graduates. 7 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform C. APPROACHES RESEARCH 34. This section provides a brief description o f the research that informed this report. More detailed information on data and methods can be found in the supplement to this report. The research included eight streams o f work: Case studies in the ES CARICOM; case studies in selected OECD countries; a survey among cohorts o f nurse graduates in Jamaica; supply and demand projections for the ES C A R I C O M under different policy scenarios, estimates o f nurse wage differentials between ES C A R I C O M countries and the US, cost estimates for strengthening and scaling-up nurse training according to different policy scenarios, cost and benefit estimates from training nurses in the ES C A R I C O M and several literature reviews (Tablel). Table 1: Main Research Activities Streani of Work Primary Sources of Informatioir Purpose Case studies o f ES i MOH, nursing schools, hospitals as Determine characteristics and trends CARICOM countries well as census o f the nurse labor and education (Guyana, Jamaica, St. market o f the English-speaking Lucia, St. Vincent and CARICOM the Grenadines; and Trinidad and Tobago) Case studies o f selected Census, nurse registers, and nurse Determine stocks, flows and driving OECD countries examination data forces o f migratory flows from the (Canada, U.K., USA) ES CARICOM to main destination countries Jamaican Nurse Survey Jamaican nurse graduate cohorts Identify and determine the role o f (1980, 1990,2000,2005) factors driving labor and education market behaviors o f ES CARICOM nurses Supply and demand Case studies o f ES CARICOM Project supply and demand for projections for the ES countries, Jamaica Nurse Survey, UN nurses in the ES CARICOM under CARICOM Population Division (2007), and various policy scenarios I CanadianNurses Association (2002) Nurse wage differentials I Country case studies in the ES Confirm wage differentials as a key across ES-CARICOM CARICOM, M O H Barbados, country factor determining migratory flows; countries and the US case study US. predict direction o f flows within the ES CARICOM under the full implementation o f the CSME Costs o f strengthening Country case studies in the ES Estimate the costs o f strengthening and expanding nurse CARICOM and scaling-up nurse training in the training ES CARICOM according to various policy scenarios Costs and benefits o f Case studies o f ES CARICOM Estimate the costs and benefits o f training nurses in the ES countries, TJK Council o f Deans, training nurses in t h e CARICOM to CARICOM World Bank Doing Business Report, defme a fair financing model that World Development Indicators assigns costs to those who benefit Literature Reviews Published and grey literature Validate and contextualize findings as well as to establish the evidence- base for recommendations 8 The Nurse Labor and Education Markets in the English-Speaking CAKICOM: Issues and Options for Reform ES CARICOM Country Case Studies 35. In close collaboration with governments, we studied the nurse labor and education markets o f five ES CARICOM countries: Guyana (GY), Jamaica (JM), St. Lucia (SL), St. Vincent and the Grenadines (SVG), and Trinidad and Tobago (TT). Collectively, these countries represent approximately 80 percent o f total ES CARICOM population. Findings reflect information collected and triangulated from multiple sources including the Ministries o f Health (MOH), Ministries o f Education (MOE), nursing schools and councils, and public and private health care facilities. Data was further validated through key informant interviews and information published in the literature. 36. Gathered data provided a comprehensive picture o f the regional nurse labor market including active and inactive supply, increments and attrition, demand and wages. In addition, they shed light on key features o f the education market including characteristics o f the supply (number o f schools, intake, completion rates) and i t s financing. Case Studies o OECD Countries f 37. The literature suggests that primary destination countries are the Canada, the UK and the U S (Docquier & Bhargava 2006). To explore stocks o f nurses abroad and wages, we used census data from Canada (Statistics Canada 2007), the UK (ONS 2008), and the U S (IPUMS 2007). To estimate inflows o f ES CARICOM nurses, we used registration S data from Canada (CIHI 2007), the UK (NMC 2005) and the U (NCSBN 2005). Jamaican Nurse Survey 38. We carried out a survey among graduates from nursing schools in Jamaica to identify labor and education market behaviors as well as their determinants. The survey targeted nurses who successfully completed the general nursing programs (3 year program, diploma only) o f the Excelsior Community College and Kingston School o f Nursing in 1980, 1990, 2000, and 2005. We gathered contact information o f former students with the help o f the Nursing Council o f Jamaica, public hospitals, nursing schools, and nurses themselves. The survey was conducted on the phone. Respondents were ensured confidentiality o f the information they provided. Supply and Demand Projections 39. We estimated future supply o f nurses in the ES CARICOM based on information on increments and attrition. We estimated future demand for nurses using information on current demand that we adjusted for changes in the utilization o f health services due to the demographic and epidemiological transition. For this purpose, we used a model developed for Canada that we adjusted for the l i f e expectancy o f ES CARICOM citizens. Nurse Wage Differentials 40. We estimated nurse wage differentials among ES CARICOM countries and in comparison to the US. Differentials were calculated using wage data for Barbados or the U as the point o f reference. We constructed estimates for the ES CARICOM from wage S 9 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform S scales for the public sector. W e obtained data for the U from the analysis o f census data. Data were adjusted for purchasing power parity. Costs o Strengthening and Expanding Nurse Training f 41. We estimated the costs o f strengthening and expanding nurse training according to the policy scenarios underlying the projections o f demand and supply. W e employed a budget approach, that is, we estimated costs for each calendar year. Cost data were taken from the ES C A I U C O M country case studies for Jamaica and St. Vincent and the Grenadines. Likewise, assumptions were based o n information obtained in the ES C A R I C O M country case studies. Cost Benefit Analysis 42. We carried out a cost benefit analysis o f training nurses in public schools in Jamaica with the prime objective to learn h o w to better assign costs to those who benefit. The analysis considered nurses and the governments o f Jamaica, the UK and the U S as potential beneficiaries and salaries, VAT levied o n the spending o f remittances, and savings in nurse training as benefits. Literature Reviews 43. We collected and synthesized information from the published literature, grey literature as well as the internet o n (i) nurse labor market in the ES CARICOM, (ii) the the nurse education market in the ES CARICOM, (iii) CSME, (iv) demand for nurses in OECD countries as well as entry regulations o f Canada, the UK and the US, (v) the production function o f nurse education, (vi) determinants o f nurse workforce performance, (vii) GATS, and (viii) uni-, bi- and multi-lateral initiatives to manage migration o f health professionals in the Commonwealth. This information was used to inform the design o f case studies and surveys, to validate and contextualize findings as well as to establish the evidence-base for the discussion o f alternative policy options. IO The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform D. THECARICOM 44. The CARICOM i s a community o f primarily English-speaking Caribbean countries that promotes regional integration and trade. Since i t s inception in 1973, the CARICOM has emphasized the "promotion o f functional cooperation, especially in relation to human and social development, and in integrating the economies o f Member States" (CARICOM 2008). To this end, the CARICOM has devised health, environment, science and technology, tourism, and foreign policies that serve to benefit all Member States. An I integral piece o f Box 1: The Caribbean the CARICOM i s The broadest definition o f the term, the Caribbean, i s the geographical the management interpretation o f a region consisting o f the Caribbean Sea, i t s islands, and the o f the Common surrounding coasts. Market, which aims to liberalize Caribbean Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Islands British Virgin Islands, Cayman Islands, Cuba, Dominica, trade in goods Dominican-Republic, Grenada, Guadeloupe, Haiti, Jamaica, among its Martinique, Montserrat, Navassa Island, Netherlands members. Over Antilles, Puerto Rico, St. Barthelme, St. Kitts and Nevis, St. 95 percent o f the Lucia, St. Martin, St. Vincent and the Grenadines, Trinidad goods produced in and Tobago, Turks and Caicos, and the United States Virgin Islands. the region move Other countries freely within the with a Belize, Colombia, Costa Rica, French Guyana, Guatemala, CARICOM. In Caribbean Guyana, Honduras, Nicaragua, Panama, Suriname, and keeping with i t s coastline Venezuela. goal to foster economic, regional integration, Suriname and Haiti have become full members over the past decade. Notably, both are non-English-speaking countries. CARICOM also pursues ambitions to become increasingly competitive and active in the Latin American and global trade market. Bilateral trade agreements with Venezuela, Colombia, the Dominican Republic, Cuba, and Costa Rica and full and effective participation in multilateral trade negotiations (e.g. Free Trade o f the Americas and the World Trade Organization) have strengthened CARICOM's position in the global trade market. 45. While CARICOM member countries have a similar history, culture, and tradition o f democratic governance as well as shared common socio-economic goals, they are highly diverse with respect to population size, socio-economic development, and health outcomes (Table 2). Geographical size ranges from Anguilla with an area o f 91 square kilometers to Guyana on the mainland o f South America with 215,000 square kilometers. Population size varies from as small as approximately 48,000 in St. K i t t s and Nevis to 9.53 million in Haiti (World Bank 2007). Economic diversity ranges from Trinidad and Tobago's primarily petroleum based economy to that o f tourism and manufacturing in Jamaica and agriculture and mining in Guyana. There i s also a wide variety in human development achievements with Antigua and Barbuda, Barbados, Bahamas, and St. Kitts and Nevis ranked according to the human development index as high level countries, and all other countries ranked as medium level countries with the notable exception o f Haiti (low level). 11 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Montserrat Yesa English St. Kitts and 0.821 Yes English 48,000 13,129 17.5 Nevis (HI 0.795 St. Lucia Yes English 164,800 8,879 12.5 74.17 (MI St. Vincent 0.761 and the Yes English 119,100 6,431 17.4 71.18 Grenadines (M) 0.774 Suriname Yes Dutch 452,500 6,702 29.5 69.78 (MI Trinidad and 0.814 Yes English 1,323,700 18,818 32.3 69.41 Tobago (H) 12 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform 46. T h e commonalities and differences across CARICOM member countries allow them to benefit f r o m regional cooperation and integration. Member States recognize that being part o f the C A R I C O M i s beneficial, and they are bridging differences and highlighting commonalities. The C A R I C O M facilitates the intra-regional trade o f diverse natural resources, skills, and services. I t pools resources and integrates markets to increase the competitiveness o f member countries in the global market. Acting as a single entity in bilateral and multilateral negotiations strengthens the voice o f the Caribbean globally and helps lobbying for i t s interests. Working together helps C A R I C O M countries to realize their common objectives o f full employment, efficient use o f resources, and increased global competitiveness, all o f which will facilitate achieving sustained economic development and improving the standard o f living in all member states. 47. T h e C S M E i s designed to create a single market where people, goods, services, and capital move freely. The CSME extends the Common Market to include free trade and movement o f goods, services, capital, and skills by eliminating intra- regional barriers. Other key elements o f the CSME include the Right o f Establishment, that is the right o f businesses to Table 3: C S M E Modes o f Free Movement establish operations without o f Services restrictions in any member state; the harmonization o f legislation Mode 1: Cross- Definition: Through cross border and economic, monetary, and border supply trade, that i s from one territory t o fiscal policies; the establishment o f another common standards and measures Examples: Tele-medicine, distance for equivalency and accreditation; training, and e-banking M o d e 2: Definition: Through consumption the harmonization o f standards to Consumption abroad, where the consumer moves t o ensure acceptability o f goods and abroad access the service services traded; the creation o f a Examples: Tourist, student, or patient common external tariff and a receiving services in host country common trade policy; and the M o d e 3: Definition: Through commercial Commercial presence, that i s where a business i s promotion o f free movement. The presence established in the place where the C S M E is being implemented in a service i s being used phased approach with the Examples: Domestic subsidiaries o f consolidation o f the Single Market foreign insurance companies, hotel and the initiation o f the Single chains, banks, o r construction companies Economy by 2009. Mode 4: Definition: Through temporary 48. Free movement of Presence o f movement o f persons, where persons natural persons o f one member enter the territory o f services and skills and free travel another member t o supply a service will increase intra-regional Examples: Health care providers, mobility and integration o f labor teachers, and accountants markets. Free movement o f Source: CARICOM Secretariat. services will enable businesses, corporations, banks, insurance companies, engineers, medical personnel, and other self- employed service providers o f any member state to offer services throughout the region and without restrictions. The main objective is to facilitate trade and investments in the service sectors o f the region. Consumers will be able to choose among a wider range o f 13 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform service providers, thus encouraging competition and offering higher quality o f services and lower costs for consumers. To this end, the CSME includes four modes o f free movement (Table 3). The free movement o f skills will allow individuals to seek employment in any member state without the need for permits to stay and work; however, to work a Certificate o f Recognition o f C A R I C O M Skills Qualification i s required which can be obtained from the designated ministry o f the home or host country. In a first phase, free movement o f skills will be limited to university graduates, professional nurses, tertiary-trained teachers, media persons, artists, musicians, and sportspersons. Once the provisions relating to free movement o f services are combined with the Right o f Establishment (see above), other professionals will be able to freely move within the region, e.g., business owners, the self-employed, managerial, technical, and supervisory staff as well as spouses and immediate, dependent family. In recognition o f the need for regional accreditation bodies which serve to assess qualifications for equivalency, member states have agreed on the Accreditation for Education in Medical and other Health Professionals. F r e e travel will allow C A R I C O M nationals to travel into and within the region. A defining symbol o f the C A R I C O M will be the C A R I C O M passport. 49. The CSME will be implemented in an environment o f tertiary sector predominance, relatively high unemployment, and significant migratory net-flows. O n average, the economies o f C A R I C O M member states are driven by service industries, employing approximately 60 percent o f the labor force. About 12 percent o f the labor force are unemployed with two-thirds being women. Annually, the region experiences negative net migration flows o f approximately 2 percent o f its population. As we demonstrate in the following section, the situation in the nurse labor market is different as unemployment among nurses is close to zero percent and annual net migration flows on average are approximately 6%. 14 The iViirse Labor and Education Markets in the English-Speaking CARICOM. Issues and Optionsfor Reform E. LABOR THEE S CARICOM NURSE MARKET I n this section, we present key features o the ES CARICOM nurse labor market. f Specijkally, we examine the active supply o nurses, the demandfor nurses, the inactive f supply o nurses, and intra-regional dynamics. f Active Supply of Nurses 50. We estimated that there were in 2007 approximately 7,800 nurses working in the ES CARICOM. Our analysis o f the nurse labor markets indicated that there were nearly 6,300 active nurses in the case study countries. Extrapolating from the case study countries, we estimated that there were approximately 7,800 active nurses in the ES CARICOM. 51. The portrait that emerged from looking at one country in the region, Jamaica, indicated that a very high proportion o f nurses were married women with children who contributed a significant portion of their household income, and whose main reason to enter the field o f nursing had been to acquire the s k i l l s to help other people. The findings from the Jamaica Nurse Survey indicated that o f those nurses interviewed, 99 percent were women. Among the nurses who graduated in 1980, 1990, and 2000, at least h a l f o f them were married and o n average had one or two children. Characteristics o f nurses and their families, such as the educational attainment o f nurses' parents, were more heterogeneous in nature. Approximately 9 out o f 10 nurses interviewed reported contributing at least half o f their household income, indicating that nurses were significant wage earners in their households. The most cited reason for entering the nursing profession was "the ability to help people". Other, commonly cited reasons included j o b security and "earned respect o f their family". The findings were consistent with literature describing factors affecting an individual's motivation to work as a health professional (Manongi et a1 2006, Mathauer & I m h o f f 2006). 52. Over 90 percent of all nurses worked in the public sector. O n average, the vast majority o f nurses worked in the public sector, however, data varied from country to country. For instance in both St. Lucia and Guyana, an estimated 20 percent to 25 percent o f all nurses worked in the private sector. Implication o f this finding is discussed . in greater detail in Section I For now, we note that these l o w rates o f participation in the private sector may signal room for increasing employment in the growing private health care market in the ES CARICOM. 53. Close to three quarters o f all active nurses worked at the secondary and tertiary care level. Approximately 72 percent o f nurses in the ES C A R I C O M provided secondary and tertiary care. An additional 1 3 percent carried out administrative and managerial functions. Variations in the proportion o f nurses in administrative and managerial functions across countries were largely explainable. For example, in smaller countries, the higher proportion o f nurses carrying out administrative and managerial f i c t i o n s could be attributed to the number o f nurse management positions being relatively independent o f the size o f facilities. 15 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform 54. The converse o f high participation in secondary and tertiary care was a low participation o f nurses in primary care. Less than 10 percent o f all active nurses were directly involved in the provision o f primary care. This proportion varied from 5 percent in Guyana to 15 percent in both S t Lucia and St. Vincent and the Grenadines. Variations among countries could be explained by the existence o f nursing cadres specifically trained for outreach activities to prevent diseases and promote health. With stabilizing but relatively high HIV/AIDS and growing non-communicable disease prevalence rates (e.g., diabetes, heart disease, and stroke), the overall l o w proportion o f nurses providing primary care has important implications for the region's ability to efficiently prevent and control such conditions through activities including patient education and behavior change communication (UNAIDS 2007, Hennis & Fraser 2004). Indeed, previous studies in the C A R I C O M indicated that the primary care services most efficiently performed by nurses, for example, glycemic controls in diabetic patients, need to be strengthened and scaled-up (Hennis & Fraser 2004). 55. Absolute numbers o f active supply translated into an average o f 1.25 nurses per 1,000 people in the ES C A R I C O M with roughly 1 nurse per 1,000 people involved in the provision o f care. Values ranged from 0.55 nurses per 1,000 people in Guyana to close to 3 nurses per 1,000 people in St. Vincent and the Grenadines. Nurse per population ratios must be examined in light o f the ratios for other human resources for health. A s such, there were no strict criteria for determining the number o f nurses any given country should have. However, comparisons with other middle and high-income countries suggested that the observed levels were low. Though they report shortages, nurse per population ratios in middle and high-income countries were up to 10 times S higher than the average in the E CARICOM. For example, a recent estimate for the nurse per population ratio in the U S was 7.7 (Buchan et a1 2005, HRSA 2002). Demand f o r Nurses 56. The demand for nurses outweighed supply with approximately 30 percent o f all approved positions for nurses vacant at the time o f the study (Figure 1). We estimated demand for nurses as the sum o f current supply and unmet demand. As a proxy for unmet demand, we used the number o f funded nursing positions that were not filled (vacancies). For the case country studies, we estimated that there were approximately 2,765 vacancies. Vacancy rates were highest in Guyana with over half o f all approved and funded positions vacant. Absolute numbers o f vacancies in case study countries translated into an average o f 0.55 vacancies per 1,000 population. Extrapolating from case studies, we estimated that there were approximately 3,340 vacancies in the ES CARICOM. 16 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Optionsfor Refornz Figure 1: Nurse Shortages in Case Study Countries GY Total JM Demand (per 1,000 population) Supply (per 1,000 population) TT S VG Source: Authors' calculations based on country case study data. 57. Vacancy rates were highest in p r i m a r y care settings. Interestingly, although nurses providing primary care represent less than 10 percent o f all nurses, in one country where we were able to obtain vacancy rates by care setting (Guyana), vacancy rates in primary and community settings represented as much as 30 percent o f all vacant positions. This observation reaffirmed the finding o f l o w participation and the reported need to strengthen primary care to respond to increasing importance o f disease prevention and health promotion. 58. Vacancy rates, as an indicator o f unmet demand, may understate the true needs, in particular o f poorer countries in the region. Vacancy rates may not adequately predict human resource needs, as they are based on approved positions in the public sector and thus subject to budgetary constraints. Indeed, our analysis demonstrated that poorer countries in the region had fewer approved positions for nurses per 1,000 people and because it i s unlikely that these countries have fewer health needs, we conclude that the number o f vacancies in these countries may be an under- representation o f the true need for nurses (Figure 2). 17 The Nurse Labor and Education Markets in the English-Speaking CARICOM: lssues and Optionsfor Reform 0 1 . ! r 75 8.0 8.5 9.0 9.5 10.0 Log of GDP per capita, PPP (current int'l$) (2005) Demand (per 1000) Supply (per 1000) Source: Authors' calculationsbased on country case study data and WDI and GDF databases, World Bank (2007). Inactive Supply o f Nurses 59. Based on the Jamaica nurse survey, it did n o t appear possible to fill vacant positions by mobilizing trained nurses who are inactive as rates o f participation in the labor market appeared to be very high. The survey o f Jamaican nurses indicated that the proportion o f nurses that was not working as a nurse was very small (Table 4). While selection bias may have limited access to those individuals who were working outside o f nursing, the high response rate we obtained (79 percent o f the valid sample) made i t likely that even if a bias was present, the magnitude was small. The observed low level o f inactive supply makes the ES CARICOM distinct from many other regions where a large number o f nurses decide not work at all or work outside the field o f nursing (Vujicic & Evans 2005, OECD 2004). 18 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Eniplo?merit Status Number 1 Full-time, nurse I 152 I 1 Part-time, nurse I 3 I Retired 2 Studying 1 Full-time, occupation other than nurse 1 1 Unemployed I 0 I Others 0 Total 159 Source: Jamaica Nurse Survey (2008). Intra-regional Dynamics 60. Intra-regional migration did not substantially impact individual countries' nurse labor markets. Looking beyond the individual countries' nurse labor markets to the ES CARICOM, we found little evidence for significant intra-regional migratory flows. In the case studies, we identified only three nurses that migrated from country to country during the period 2002 to 2006. Likewise, the survey among Jamaican trained nurses identified only 3 out o f 159 nurses that l e f t Jamaica to work in different CARICOM countries. As we discuss in section H, intra-regional migratory flows may, however, increase with the full implementation o f the CSME. Increments and Attrition 61. Jointly, the ES CARICOM countries faced a fragile equilibrium of increments and attrition. While the total increment rate, was approximately 10.5 percent, the attrition rate was roughly 8 percent. Increment and attrition rates varied significantly across countries. 62. L o c a l graduates and recruits from abroad constituted the main sources of increments. Flows from both sources are discussed separately in the following sections. In summary, graduates from local nurse programs constituted the main source o f increments. Net education increment rates varied across countries from 6 to 9 percent. In addition to training nurses, some countries recruited nurses from outside the region. 63. Outmigration was the main source of nurse workforce attrition. Attrition rates varied tremendously across countries with Guyana reaching a record high o f approximately 20% in 2007. Outmigration was the main source o f attrition, accounting on average for approximately 70 percent o f losses. Detailed findings are presented in the following section. 19 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform F. LABOR NURSE INTERACTIONS BETWEEN THE ES CARICOM ANDTHE GLOBAL MARKETS The ES CARICOM nurse labor market cannot be fully understood without information about the interaction with lhe global nurse labor market. I n this section, we examinefirst emigration patterns including the stock o ES CARICOM-trained nurses in prime f destination countries, trends o migratory outflows, and factors determining the f migration decision. Furthermore, we present inflows o nurses into the region, including f ES CARICOM nurses returning home as well as foreign-trained nurses. Stocks of Caribbean-TrainedNurses in Prime DestinationCountries 64. Prime destination countries o f nurse migrants from the E S CARICOM are Canada, the UK and the US. The ES CARICOM has strong linguistic, educational and historic ties and commonalities with Canada, the UK and the US. Previous studies demonstrated that these ties and commonalities facilitate migration with the effect that Canada, the UK and the U are the prime destinations o f migrants, and in particular S health migrants from the ES CARICOM (Thomas-Hope 2002, Dawson 2005). 65. We estimated that the number o f E S CARICOM trained nurses working in the prime destination countries was roughly three times as high as the number of nurses working in the ES CARICOM. We estimated that roughly 750 nurses trained in the ES CARICOM were living in Canada, 4,750 nurses trained in the ES CARICOM in the UK, and 15,500 nurses trained in the ES CARICOM in the US. To our knowledge, the ratio o f health migrants (21,500) compared to the locally remaining stock (7,800) i s without parallel in the world (Clemens & Pettersson 2008). Estimates o f nurse stocks in prime destination countries were derived from census data from 1980, 1990, and 2000 in the U S and from 2001 census data for Canada and the UK. All census data presented the limitation that they detailed only the occupation but not the training, l e t alone in which country the respondent received her training. We tackled the challenge o f distinguishing between migrants trained in the ES CARICOM versus the U S by adjusting estimates for the age o f migration and dynamics o f cohorts. However, we did not adjust for the fact that the U S census does not identify migrants trained in the ES CARICOM that are not practicing their profession. Consequently, the presented estimates may underestimate the true number o f ES CARICOM trained nurses in the prime destination countries. Trends o f Migratory Outflows 66. We estimated recent trends o f migratory outflows using data derived from registration processes in destination countries. Recognizing that the stock o f nurses abroad was the result o f migratory flows over period o f several decades, we estimated S trends o f recent outflows based on the number o f E CARICOM trained nurses initiating or completing the registration process in prime destination countries. For Canada and the UK, we obtained information on nurses successfully completing the registration process. For the US, we used data from the Nursing Council Licensure Examination V C L E X ) . 20 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform 67. We estimated that more than 1,800 nurses emigrated from the ES CARICOM to Canada, the UK and the U S during the period 2002 to 2006. Based on data obtained from the Canadian Institute for Health Information (CIHI), we estimated that 170 ES CARICOM trained nurses registered in Canada between 2002 and 2006. Analyzing data obtained from the UK Nursing and Midwifery Council, we estimated that 1,150 ES CARICOM trained nurses registered in the UK during the same time period. NCLEX data suggested that approximately 495 ES CARICOM trained nurses migrated to S the U between 2004 and 2006. In sum, we estimated that at least 1,800 ES CARICOM nurses migrated to the three prime destination countries to seek work between 2002 and 2006 (Figure 3). Figure 3: Flows o f ES CARICOM trained Nurses to Prime Destination Countries between 2002 and 2006 2001/20u2 2002/2003 200312004 200412005 200512008 Source: Authors' calculations based on Canadian Institute for Wealth Information (2006), the UK Nursing and Midwifery Council (2005), and the U Nursing Council Licensure Exam (2004-2006) S 68. Estimates of large stocks o f ES-CARICOM trained nurses in prime destination countries and continuous out-flows correlated well with results o f the Jamaican nurse survey. Approximately 30 percent o f Jamaican graduates lived abroad, the vast majority (90 percent) in Canada, the UK and the U S (Table 5). The percentage o f migrants varied dependent on the year o f graduation. The proportion o f migrants among the 2000 and 2005 cohorts was very small, suggesting that the current 5-year bonding policy was effective. However, the proportion o f migrants among the 1990 cohort was 61 percent and for the 1980 cohort 86 percent. The proportion o f migrants may be even underestimated in the survey. We identified the residence o f only 79 21 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform percent o f graduates. As it was more difficult to identify migrants, the proportion o f them among the non-participants may therefore even be higher than among survey participants. Table 5: Residency o f Jamaican-trained Nurses for Cohorts o f Nurse Student Graduates Jamaica 6 20 58 86 170 Bahamas 0 1 0 0 1 I Bermuda I 1 I l I O I O 1 2 1 I Canada 1 4 1 1 / 0 / 0 1 5 / Europe 0 1 0 0 1 UK 1 3 1 0 5 I Other I Sub-totalAbroad 1 38(86%) I 31 (61%) I 8(12%) 1 1(1%) 1 78(31%) I Source: Jamaica Nurse Survey (2008) 69. Flow rates into prime destination countries appeared to b e declining; however, a change in entry regulations could quickly reverse this trend and deplete the current stock o f ES CARICOM nurses. The comparison o f stocks to outflows suggests that past flows had been significantly higher. For example, if more recent flows reflect past migratory patterns, we would have expected a stock o f approximately 11,500 rather than 21,500 nurses in prime destination countries. However, i t i s important to note that because nurse migration from the ES C A R I C O M i s fundamentally constrained by entry regulations and nursing bodies' accreditation policies in prime destination countries, any relaxation o f these constraints may cause nurse emigration levels to return to or exceed i t s historically high levels. In the U S alone, it has been estimated that there will be shortage o f over 800,000 nurses by the year 2020 (HRSA 2002). Because projected demand far outstrips the U S ' current training capacity for nurses, there i s a very real possibility that authorities may ease entry regulations. This would potentially cause massive levels o f immigration o f ES C A R I C O M nurses. In fact, in 2005 the U S instituted a new immigration policy that provided 50,000 permanent residency visas specifically for nurses (Arendes-Kuenning 2006). Similarly, substantial increases in nurse shortages have also been projected for Canada. Unmet demand i s expected to reach 78,000 nurses in 201 1 and 113,000 in 2016 (Canadian Nurse Association 2002). 70. M i g r a t i o n appeared not only to cause significant shortages o f nurses in the region but it also may b e taking some o f the brightest nurses. Although subject to recall bias, when asked about class rank in the Jamaica Nurse Survey, nearly all migrants indicated being in the top 30 percent o f their class with 67 percent indicating that they 22 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Options for Reform were in the top 10 percent (Table 6) . 81 percent o f non-migrants also reported being in the top 30 percent with 45 percent o f non-migrants interviewed reporting being in the top 10 percent. Because we would anticipate that the mean class rank for all nurses in the sample should be at the 50th percentile, it i s likely that there i s a systematic bias present in nurses recalling their class performance and/or a bias in the sample o f nurses interviewed where stronger students were easier to locate and more willing to be interviewed. Nonetheless, there appears to be a division between migrants and non- migrants o n academic performance. Table 6: Class Rank o f Nurses, by Non-Migrant and Migrant R N s , R N s Interviewed Top 50% 4 1 5 Bottom 50% 0 0 0 Total 22 27 49 Source: Jamaica Nurse Survey (2008) F Factors Determining the Migration Decision 71. U S immigration and entry regulations create a quasi-experiment that allowed u to identify determinants o f migratory flows. U S immigration and entry s regulations provide conditions to test hypotheses about migration in a quasi experiment. In contrast to other destination countries, the U S does not give preferential treatment to citizens o f foreign countries under, for example, bilateral agreements. Instead, applicants are treated independent o f citizenship on a first come, first served basis. Thus, they S compete for entry into the U and, as a result, the volumes o f country-specific immigration flows correlate with the demand and population size in the source country. 72. Migratory flow rates from ES C A R I C O M countries to the U S appeared to correlate directly with the GDP per capita differential (Figure 4). Using this quasi- experimental design, we tested the role o f socio-economic development as a predictor o f migratory f l o w rates o f nurses. Specifically, we compared GDP per capita differentials S and flow rates to the U for the five case study countries as well as Barbados, Belize, Dominica and Grenada. While the data set i s too small to test for statistical significance, f l o w rates appear to correlate with GDP per capita differentials. 23 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Figure 4: Flow Rates in Relation to GDP I .. + TT __._. .. .. .. . __ .__ . . . I .*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....... ..I ! BAR i . .__-- ....... ; ... SL i _ _ + GND - -+ + t DO *I - - - .i SVG BEL JM 0.0% 1 .O% 2.0% 3.0% 4.0% 5.0% 6.0% Nurse outflow to USlDomesitc Supply S Source: Authors' calculations based on U NCLEX data and W D I and GDF databases, World Bank (2007) Figure 5: Flow Rates in Relation to Wages 70 % SL TT 60 % + + SVG 50 % * Jtil GY I 40% ) . 30% 0 0 01 0 02 0 03 0 04 0 05 0 06 Nurse Outflow t o US/ Dorneslic supply Source: Authors' calculations based on country case study data, wage information kindly provided by the Government of Barbados and U S NCLEX data (2007) 24 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform 73. Likewise, migratory flow rates f r o m ES CARICOM countries to the U S appeared to correlate directly with wage differentials (Figure 5). The literature suggests that wage differentials are driving forces o f migratory flows (Vujicic et al, 2004). Therefore, we also compared the role o f wage differentials as a predictor o f migratory f l o w rates o f nurses to the US. The available data set was smaller than for GDP per capita, however, a s i m i l a r pattern occurred. Trinidad and Tobago appeared to be an outlier as wage differentials would suggest a higher rate o f migratory rates o f nurses. This phenomenon may be the result o f most recent, fast economic growth that has yet to translate into higher wages for health professionals and specifically for nurses as well as other efforts to improve the work satisfaction. 74. T h e importance o f wages for the migration decision was confirmed by observations o f the Jamaica Nurse Survey (Table 7, 8, and 9). Approximately 95 percent o f Jamaican nurses who migrated reported that a key motivation for the decision to migrate was to earn a better salary. Furthermore, 85 percent o f migrant nurses were satisfied with their salary, but only 6% o f non-migrant nurses. Finally, satisfaction with remuneration improved after migration. W h i l e 9 1% o f migrants were satisfied with their salary after migrating, only 32% were satisfied with their salary prior to going abroad. Source: Jamaica Nurse Labor Survey (2008) Country of Residence Jamaica Abroad vs S D VD vs S D VD Salary 0 (0%) 8 (6%) 52 (41%) 68 (53%) 5 (19%) 18 (66%) 4 (15%) 0 (YO) Source: Jamaica Nurse Labor Survey (2008) 25 The Nurse Labor and Education Markets in the English-Speaking CAIUCOiM: Issues and Options for Reform 75. The importance o f wages for the migration decision seemed to be associated with the frequency o f migrants sending remittances. Nearly 80 percent o f migrants participating in the Jamaica Nurse Survey reported that they send remittances to family members in their home country. The magnitude o f remittances was o n average approximately U S $ 2,500 per year or 5% o f net income with slight variations across cohorts. 76. I n addition to wages, satisfaction with other work-related factors played an important role (Table 10, 11, and 12). The Jamaican Nurse Survey suggested that for four out o f five migrants more interesting work and better career development opportunities abroad were key factors in their migration decisions. Likewise, the survey demonstrated that levels o f satisfaction with the work environment as well as work and career opportunities was consistently higher among migrants than nurses working in Jamaica. Furthermore, satisfaction with the work environment and work and career development opportunities improved after migrating. While 86% were satisfied with the work environment and 91% with work and career development opportunities after migrating; only 55% were satisfied with their work environment and 50% with work and career development opportunities prior to migrating. Keasoris Given for Entigrition Not Im porta nt Iniporta nt Tota t - - - - - - t Provide good education opportunities for children 12 (40%) 18 (600'6) 30 Better work and career development omortunities 6 (19%) ' 25 (81%) 31 Source: Jamaica Nurse Labor Survey (2008) Table 11: Satisfaction with Work Environment and Work and Career Development Opportunities, by Country o f Residence, RSs Interviewed Cuuirtry of Residence - . .- _ . - -- - -. Jamaica Abroad vs S D VD VS S D VD Work 4 52 53 20 4 19 4 0 Environment (3%) (40%) (41%) (16%) (15%) (70%) (15%) (0%) Work and Career 47 63 9 13 10 4 0 Development (7%) (37%) (49%) (7%) (48%) (37%) (15%) (0%) Opportunities 26 The Nurse Lnbor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Table 12: Satisfaction with Work Environment and Work and Career Development Omortunities Before and After Mieration. F W s Interviewed I 1 Work Environment Work and Career Development Omortunities I 11 (50%) I 11 (50%) 1 20(91%) I 2(9%) 1 Source: Jamaica Nurse Labor Survey (2008) 77. Established social networks with the Diaspora in destination countries appeared to facilitate the migration decision and to direct migration flows. Survey data showed that an estimated 90 percent o f migrants knew at least one person (e.g., parent, spouse, child, sibling, relative, classmate, or colleague) living in the destination country and, in particular, in the area where they finally settled prior to moving abroad. Moreover, 80 percent o f the migrants identified in the Jamaica Nurse Survey living and working in the U had settled in two states, N e w York and Florida. Likewise, the S analysis o f the 2000 U S census showed that 90 percent o f the estimated 8,600 Jamaican nurses living in the U S had settled in New York (50 percent) and Florida (37 percent). These data suggested that nurses tended to migrate to areas where communities similar to home already exist. Moreover, they suggested that the networks formed between non- migrants, migrants, and returning migrant serve to share information about the process as well as to convey the benefits o f migration. 78. Conversely, insufficient access to information about migration was one o f the main reasons given as to why nurses working in Jamaica have not migrated. More than half o f Jamaican nurses, who have never lived abroad, stated that the main reason for remaining in their home country was the lack o f information about migration opportunities. Given this finding, i t i s likely that subject to the availability o f visa an improved access to information i s likely to result in higher migration rates (Table 13). 79. The Jamaican Nurse Survey identified two other main reasons for the decision to remain in the home country: an effective bonding scheme and family considerations (Table 13). As mentioned earlier, the government's bonding scheme appeared to be effective. Only one nurse o f the 2005 cohort o f graduates obliged to serve at home had migrated. Furthermore, migrants among the 1980 and 1990 cohorts had worked o n average more than 8 years in Jamaica before deciding to move and work abroad. Finally, approximately 10% o f all interviewed nurses reported that their obligation vis-a-vis the government was the main reason for remaining and working in their home country. Evidence to what extent family considerations influenced the decision to migrate was more mixed. Approximately 60 percent o f migrant nurses stated that the prospect o f better education opportunities for their children played an important role in their decision to migrate. However, only approximately 15 percent o f interviewed non-migrant nurses stated that family ties were the main reason to remain in their home country. Furthermore, the proportion o f nurses who had married prior to graduation was somewhat higher among migrants compared to non-migrants as well as the proportion o f nurses who had a child prior to graduation (Table 13). 27 The Nurse Lnbor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Bonded 12 (10%) Like my home country 9 (8%) Want to gain more experience before migrating 3 (2%) Like my iob 2 (2%) Generally not interested in migrating 1 (1%) Total 120 Source: Jamaica Nurse Labor Survey (2008) Inflows 80. The Jamaica Nurse Survey revealed that close to three-quarters o f migrants intended to return home; however only half reported that they would return to work as a nurse. Information about the number o f nurse migrants who returned to their home country and worked as a nurse was scarce and anecdotal. Hence, as a proxy, we researched the intent to return. And indeed, survey results suggested that a high proportion o f migrants intend to return. A variety o f reasons were given, ranging from an obligation to care for parents, a desire to contribute to their home country, and simply because `it i s home'. However, it remained uncertain whether this intent would translate into actual return migration. Furthermore, it i s important to note that only 50 percent o f those who stated that they intend to return home plan to work as a nurse. 81. I n addition to return migrants, the inflow o f foreign nurses represents a small but important source o f new nurses. Case study date suggested that between 2002 and 2007 approximately 1,000 foreign nurses entered the ES C A R I C O M to practice their profession. Cuba was the major source country followed by India, Nigeria, and the Philippines. Flows from these countries were not constant throughout this 6-year time period. Migrants entered in waves, likely facilitated by short-term agreements between governments and/or health training and delivery institutions. I Box 2: Recruitment of Foreign Nurses in Trinidad and Tobago In an effort to address nurse shortages, Trinidad and Tobago's Ministry o f Health has recruited foreign nurses under bilateral agreements. The recruitment o f foreign nurses was strategically targeted to certain specialties for which there i s high demand. In 2003, a first group o f nurse migrants came from Cuba. Since then, almost a hundred Cuban nurses have been recruited; more than 70 percent o f them trained at the Bachelor's degree level. More recently, Trinidad and Tobago has begun recruiting Filipino nurses. Filipino nurses' high quality training and proficiency in the English language distinguish them from nurses in other possible source countries. Since 2005, almost 200 Filipino nurses have been recruited. 28 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Options& Rejorni G. THEES CAKICOM NURSE MARKET EDUCATION I n this section, we describe the supply o nurse education, including segments created by f different financing models, identi& supply-side constraints, explore demand for nurse education, and summarize ongoing and planned reforms. 82. I n the case study countries, w e identified 43 pre-service (general nursing) and in-service (post-basic) programs offered at 24 nursing schools, with variation among countries by number o f schools, size o f programs, and degrees. In all case study countries, schools offered general nursing (3 years diploma), midwifery, and nursing assistant training programs. In Guyana, Jamaica and Trinidad and Tobago, schools also offered post-basic programs (e.g., public health, critical care, operating theatre, nurse management, and nurse tutor programs). In the same three countries, schools also offered Bachelor Degree Programs as both pre and in-service curricula. In Jamaica, the University o f the West Indies School o f Nursing also offers a Master's degree program. 83. W e estimated that 585 students graduated in 2006 f r o m general nursing pre- service programs. According to graduation records and registers, 470 students graduated n the case study countries in 2006 from pre-service, general nursing programs, the majority from diploma programs. When we extrapolated to the ES CARICOM, we estimated that 585 students graduated from pre-service programs. I t should be noted, however, that throughout the period 2002 to 2007 the number o f graduates was not constant. In Jamaica and Trinidad and Tobago, we observed fluctuations from year to year. In Guyana, St. Lucia, and St. Vincent and the Grenadines, we observed years in which no student graduated at all. 84. N e t increment rates f r o m training locally averaged 8 percent w i t h variations from 6 percent to 9 percent across case study countries. We estimated net increment rates from local training for case study countries as the ratio o f pre-service graduates compared to the total supply o f nurses. O n average the net increment rate was 8 percent. N e t increment rates were highest in Trinidad and Tobago along with St. Vincent and the Grenadines, followed by Jamaica, St. Lucia and Guyana. For now, we note that the net increment rate was lower than the attrition rate. We discuss the implications o f this finding in section H. 29 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Options for Reform Table 14: N e t Increment Rates in 2006 r I Total ES c; Y JM `FI CSC CARICORI Net increment rate t 1 I (Net increment / 8% 9% 6Yo 8% 6Yo 8Yo 8% total supply) Source: Authors' calculations based o n country case study data 85. I n the case study countries, w e observed three types o f nursing schools with different levels o f autonomy as well as sources o f funding; public, semi-autonomous, and private schools. Public schools were fully funded by governments and students paid no tuition. In the case study countries, these schools were the predominant provider o f general nursing programs. Autonomous schools enjoyed certain levels o f managerial freedom, including the right to charge tuition, but at the same time tended to receive direct subsidies from governments. Autonomous schools operated in Jamaica, St. Lucia, St. Vincent and the Grenadines, and Trinidad and Tobago. Private nursing schools were rare. We identified two in Trinidad and Tobago and one each in Guyana and Jamaica. Two out o f these four schools were run by churches. 86. I n line with free tertiary education policies, governments o f case study countries tended to finance nurse education independent o f the type o f school. As discussed above, governments operated the majority o f schools. In addition, governments tended to co-finance autonomous. In addition and independent o f the type o f schools, governments supported students in paying for their living costs and tuition through stipends. For example, under the Government Assistance for Tuition Expenses (GATE) program o f the government o f Trinidad and Tobago, tuition was free for all citizens in undergraduate programs and covered 50 percent o f tuition costs for postgraduate studies. Recipients o f GATE funding were required to work in the country for a certain number o f years upon completion o f their program. If students did not comply with this obligation, they needed to refund tuition subsidies in full. 87. At the same time, w e observed a trend towards co-payments by students. While students enrolled in the professional nurse education program in Guyana received a stipend o f GYD $15,000 per month, students enrolled in the Bachelor's degree program at the University o f Guyana had to completely finance their education, however, facilitated by loans provided by the Ministry o f Finance. In Jamaica, the government had scaled-down stipend programs for students at autonomous and private nursing schools. In line with this policy, the Jamaica Nurse Survey demonstrated an increase in the proportion o f students paying their tuition themselves. In St. Lucia, students were required to pay an annual tuition for their training (Table 15). 30 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Source. Authors' calculations based on Jamaica Nurse Labor Survey (2008) 88. Despite substantial excess demand for nurse education, private schools remain the exception. The literature suggests that countries facing high levels o f out- migration tend to experience a private sector response to unmet demand for the training o f health professionals (Clemens et a1 2007). As we demonstrate later in the report, in the case study countries, demand for nurse education significantly exceeded supply. However, we did not observe a major private sector response. We identified only three private nursing schools; all o f them receiving direct or indirect public subsidies. To our knowledge, the only fully privately financed nursing school in the ES C A R I C O M i s the Ross Nursing School in St. Kitts and Nevis (Garner 2007). It, however, primarily enrolls students from outside the region and prepares them according to U S curricula. The limited private sector response may have to major Supply-side constraints 89. T h e output o f nursing schools was limited by low completion rates. In the case study countries, on average only half o f nurse students completed their program. Although the potentially multi-factorial nature o f failing to complete a program does not allow fully disentangling this outcome, i t should be noted that there appeared to be an indirect relationship between the completion rate and the level o f student subsidization. In fact, in St. Lucia, the one case study country where students had to pay full tuition, there was the highest rate o f completion. This raised the question o f whether students who were required to invest financially in their education were less likely to drop out. Furthermore, key informant interviews in Guyana revealed that a major cause o f l o w completion rates was the failure to pass exams. Again, the potentially multi-factorial nature did not allow drawing final conclusions, the latter observations pointed to deficiencies in the qualification o f students and/or the quality o f training in some o f the schools. 90. L o w pass rates o f E S CAFUCOM nurses in the U S NCLEX also raised concerns about the quality o f education. When examining pass rates o f ES C A R I C O M nurse graduates in the U S NCLEX, ES C A R I C O M nurse graduates were consistently outperformed by their U S counterparts (figure 6). However, this data should be interpreted with caution. The N C L E X assesses abilities and skills in relative but not absolute terms, that is, in comparison to other nurses participating in the exam; furthermore, it may not reflect skill needs as in some o f the ES C A R I C O M countries and may have cultural biases. Nonetheless, among ES C A R I C O M countries, Jamaican and Belize trained nurses performed best o n the N C L E X with passing rates o f over 60 percent; whereas, passing rates o f nurses trained in other countries varied between 42 percent and 57 percent. 31 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Figure 6: U S NCLEX Pass Rates by Country o f Training in 2000-2005 $ 60.0% P X w d 50.0% 2 c3". eV Q+ V 6. iO .$a6 Qo* ( ,' .' G o d +@ W G+ Source: Authors' calculations based on Nursing Council Licensure Examination (2000-2005) 91. An insufficient number o f nurse tutors likely impeded the quality nurse education. The Caribbean Standards for Nursing Education suggest a student to tutor ratio o f 2 5 : l in the classroom and 8 : l in the clinical area. According to numbers collected for 2006, we estimated that there were 130 tutors in the case study countries, o f which 75 were directly providing training to pre-service nurse students. High drop out rates and our lack o f understanding o f when students drop out made it extremely difficult to estimate the student to tutor ratio. However, assuming that on average students who dropped out, dropped out mid-way through the programs, we estimated a 30:l student to tutor ratio. Given the need for tutors with specialized training skills and the need for providing personal attention to students through active-learning methodologies, it was likely that this ratio was too high to achieve high standards o f quality. 92. Some nurse tutors may not meet education requirements. In Jamaica, education standards require that persons teaching at the tertiary level should possess a Master's degree as a minimum qualification. However, among nurse tutors only about half met these qualifications. Hence, insufficient levels o f training among nurse tutors may exacerbate the challenge o f improving the quality o f nurse education. 93. The relative shortage o f qualified nurse tutors would be a major constraint to expand and strengthen nurse-training capacity. High student per tutor ratios and limited compliance with education requirements among tutors would likely hamper any major attempts to further expand and strengthen nurse education programs. It should be noted, however, that we observed significant differences across case study countries. At the same time, our analyses demonstrated that the number o f training sites and patients 32 The Nurse Labor and Education A4arkets in the English-Speaking CARlCOA4: Issues and Optionsfor Reform would be sufficient and not considered a binding constraint to expand and strengthen nurse education programs. As we explain below, using hospital beds as a proxy for clinical training opportunities, we estimated that the secondary and tertiary service delivery capacity would be sufficient to amplify current training capacities up to ten-fold. Demand 94. Our analyses did not identify any major demand-side constraints to scale-up nurse training in the ES CARICOM. In the case study countries, between 2004 and 2006, on average three qualified candidates competed for every position in a nurse training program (Table 16). Moreover, 1 out o f approximately 6 high-school graduates meeting minimum qualifications applied for nurse training programs. All this points to excess demand for nurse education. Together with the earlier documented excess demand for nurse labor, excess demand emphasized the need to overcome earlier identified supply-side constraints. Table 16: Key Nurse Education Demand-side Indicators Source: Authors' calculations based o n country case study data Ongoing and Planned Reforms 95. All countries in the region have been taking significant steps to strengthen and expand nurse education. For instance, Trinidad and Tobago substantially expanded intake in 2004, and thus doubled the number o f nurse graduates from 2005 to 2006. As a result, in 2006, an estimated 1,000 nursing students graduated in the five case study countries, a record high during the period we examined. Also St. Vincent and the Grenadines significantly increased their intake into nursing schools, expecting an almost three-fold increase in graduates by 2008. In addition, efforts were made to improve curricula and pedagogical approaches as well as to harmonize nurse education programs. The latter reforms were driven by the mandatory Regional Nursing Council Registration Exam (RNCRE) that graduating nurses must pass to practice in all ES C A R I C O M countries with the exception o f Guyana (Reid 2000). Despite these and other major efforts (Table 17), the following section demonstrates that additional initiatives are necessary to overcome nurse labor market shortcomings facing the region. 33 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform - Table 17: Examples of Nurse Education Reforms in the E S CARICOM Reforms to Improve Nurse Education Capacity and Quality - 8 Increase the training capacity and intake o f the nursing schools Guyana ' Provide incentives for faculty staff to prevent their migration ' Phase out all diploma and certificate nursing programs; scale-up bachelor degree programs Update qualifications o f nurse tutors from certificate and bachelor degrees to masters Jamaica degrees, and train all new nurse tutors at the graduate level ' Prepare more clinical instructors and widen the clinical specialties (at tertiary level) o f Post-basic ' Expand training o f lecturers, assistant lecturers, and clinical instructors for general nursing and midwifery disciplines St` Lucia ' Provide incentives t o staff in the clinical areas Increase intake o f nurse students St. Vincent ' Increase the intake into the program for registered nurses from 30 - 35 to 100 annually and the ' Rationalize the training o f nurses t o achieve greater efficiency Grenadines ' Strengthen nurse training programs t o attract students from abroad Trinidad L Provide free in-service programs t o expand professional development opportunities and ' Recruit nurse tutors f r o m abroad Tobago Source: Key informant interviews 34 The Nurse Labor and Education Aiiarkets in the English-Speaking CARICOM: Issues and Options for Reform H. NURSE A REGIONAL MARKET LABOR OUTLOOK I n this section, we first examine how supply and demand are likely to evolve under current policies over the next 15 years. We then examine the likely impact o alternative f nurse education policies on supply and consequently future nurse shortages and explore their costs and Jinancing options. Finally, we discuss the likely impact o the Jull f implementation o the CSME on intra-regional migratory flows o nurses. f f F u t u r e D e m a n d and Supply u n d e r C u r r e n t Policies 96. U n d e r c u r r e n t policies, with t h e exception o f r e l y i n g o n training as the o n l y source o f increments in l i n e with t h e p r i n c i p l e o f self-sufficiency, w e estimated that t h e gap between d e m a n d f o r and supply o f nurses w o u l d w i d e n f r o m 3,400 nurses in 2007 t o 10,700 nurses in 2025, Demand according to health needs o f the aging population increasingly suffering from chronic diseases would increase from 10,700 nurses today to 13,000 nurses in 2015 and 18,100 nurses in 2025. As attrition exceeds increments, over the same period, supply would slightly decrease from 7,800 in 2007 to 7,600 nurses in 2015 and 7,500 nurses in 2025. As a result, we estimated that unless there were major changes in the policy environment, nurse shortages would increase from approximately 3,400 nurses in 2007 to approximately 5,300 nurses in 2015 and approximately 10,700 nurses in 2025 (Figure 7). F i g u r e 7: Supply a n d D e m a n d f o r Nurses in the E S Speaking CARICOM U n d e r C u r r e n t Policies *- 20000 18000 16000 - i 14000 P g 12000 z 2 w- 10000 a 9 8000 - 2 6000 4000 2000 0 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 Year -Demand -Supplv SQ Source: Authors' calculations based on data from country case studies. the Canadian Nurses Association (2002), the United Nations Population Division (2007), and the World Bank's WDI and GDF databases (2007) 35 The Nurse Labor and Education hfurkets in the English-Speuking CARICOM: Issues and Optionsfor Reform Future Supply, Demand and Shortages under Alternative Policy Scenarios 97. Given that the gap between demand and supply would widen under current policies, we examined the impact o f different policy actions. Alternative policy scenarios focused on supply side interventions, namely increasing the number o f nurse graduates to expand the size o f the nurse workforce. As we discussed in section F, unilateral policy options for ES C A R I C O M governments to curb attrition were likely to be o f little impact if destination countries should decide to increasingly draw o n foreign nurses. Therefore, we did not attempt to model the impact o f local policies to curb attrition. Modeling the impact o f demand side-interventions, that is, the impact o f interventions to lower the demand for health care was beyond the scope o f this study. 98. Among possible supply side interventions, we examined the impact o f increasing the number o f graduates and consequently the supply o f nurses by expanding training capacity and improving completion rates. We analyzed two scenarios o f expanding training capacity; an increase o f intake o f students by 50 percent and 100 percent (Table 18). Furthermore, we coupled the increase in intake with improvements in completion rates. As discussed earlier, we estimated that in case study countries completion rates were o n average about 55 percent. In the scenario analysis, we assessed the impact o f increasing completion rates to 85 percent. Similar levels were achieved by several nursing schools investigated in the case country studies. Table 18: Description o f Scenarios for Scaling-up Supply I 1 I __ Base case scenario Current policies are maintained A 50 percent increase in the intake o f students into pre-service general nurse training Scenario 1 programs and increase o f graduation rate from 55 percent to 85 percent Scenario 2 A 100 percent increase in the intake o f students into pre-service general nurse training programs and increase in graduation rates from 55 t o 85 percent I 99. The proposed approaches to increasing the number o f annual graduates seemed technically feasible. Prior to estimating their impact, we investigated the feasibility o f the proposed approaches to increase the output o f training institutions. In the analysis, we concentrated on aspects o f technical feasibility. As we discuss later in this section, we believed that financial constraints could be overcome fairly easily. O n the supply side, we paid particular attention to the need for nurse tutors as well as clinical training opportunities. The availability o f these inputs to the production function was not only critical but may be difficult to boost. Furthermore, we investigated possible constraints to the demand for nurse training. As we demonstrate in the following paragraphs, any o f these constraints could be relaxed and the proposed scenarios appeared therefore technically feasible. 36 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optzonsfor Reform 100. Increasing intake and improving completion rates, however, would require substantial increases in the number o f nurse tutors. Increasing training capacities would depend o n the availability o f tutors. We assumed that the number o f tutors would proportionally increase in order to maintain the quality o f teaching. Furthermore, we assumed that improving completion rates could be achieved by reducing the student-tutor ratio. While we recognized that there were multiple reasons for l o w completion rates (e.g. drop out due to family situations, financial constraints, or loss o f interest), interviews conducted in Guyana pointed to the inability o f students to pass exams as a major cause o f l o w completion rates and, as a cause o f the inability to pass exams, to a sub-optimal quality o f training. At the same time, i t i s generally accepted that smaller class sizes allow for better education opportunities especially in clinical settings. According to the country case studies, we estimated that the student-tutor ratio was 30: 1. The Caribbean Standards for Nursing Education recommend a student-teacher ratio o f 25:l in the classroom and 8 : l in clinical settings. This recommendation, however, may not allow for adequate quality o f training, given all the specialized subjects taught, the varying sizes o f institutions, and the distribution o f schools within the region. In the scenario analysis, we therefore assumed a target student-teacher ratio o f 10: 1. In the short term, this target could be achieved by either promoting one-year online courses for nurse tutors or b y recruiting nurse tutors from abroad. In the mid term, however, nurse tutor training capacities would have to be increased. 101, With the exception o f tutors, instructors and supervisors, clinical training opportunities did not appear to b e a binding constraint to boost nurse training capacity. Clinical training i s a critical element o f the nurse curriculum. Clinical training opportunities rest not only with the availability o f tutors, instructors and supervisors, but also the number o f training sites and patients. A s a proxy for the availability o f the latter, we used the number o f hospital beds in the region. Assuming that the clinical training o f a nurse student requires approximately 5 hospital beds over a 6-months period every year, we estimated the threshold above which an expansion o f training capacities would be limited by clinical training opportunities. These estimates suggested that the secondary and tertiary level service delivery capacity was sufficient to amplify current training capacities up to ten-fold. 102. Also demand for nurse education did not appear to b e a binding constraint to increase the number o f graduates. Country case study data suggested that there were three qualified candidates competing for one nurse student position. This high demand was again confirmed by reports o f willingness to pay for nurse education (Table 19). Information collected from the Jamaica Nurse Survey suggested that almost all nurses were willing to pay for their nurse education. O n average, these nurses were willing to pay annually US$ 1,200 and the amount increased to U S $ 1,500 if there would be guaranteed access to loans. 37 The hrurse Labor and Education Markets in the English-Speaking CANCOM: Issues and Options for Reform Table 19: Willingness to Pay for Nurse Training Education among Jamaica-trained Loan and Job 1 Jamaica 1 US$ 1,221 * I US$ 1,510 * I US$ 1,803 * I us U S $ 5,832 U S $ 10,041 U S $ 2 1,942 103. There appeared to be the potential to further stimulate the demand for nursing programs in the ES CARICOM. One o f the rewards for investing in secondary education i s that there exists a large pool o f high school students meeting entry requirements. Out o f the approximately 20,000 students graduating annually from high schools and meeting minimum qualifications for nurse training, only 1 out o f 17 applied to nursing programs. While countries should promote diversity in their labor markets, the data suggested that there was room to increase the rate o f qualified graduate students applying to nursing programs. 104. Maximizing the completion rate and increasing intake by 50 percent would result in a 230 percent increase in the number o f annual nurse graduates. The combined measure o f improving the completion rate from an estimated 55 percent to 85 percent and increasing the intake into pre-service training programs by 50 percent would result in a gradual increase in the annual number o f graduates from 585 in 2007 to 1,340 in 2015 and constant thereafter. In terms o f the nurse workforce, this related to an estimated increase o f 2,400 nurses in 2015, and 6,200 in 2025. Achieving this increase, however, would require dramatically increasing the number o f nurse tutors from currently 90 to 510. The analysis assumed attrition to remain the same. However, it should be noted that all efforts to increase training capacity by increasing the intake o f students by 50 percent and improving completion rates would be offset if the attrition rates would increase from 8 percent to 18 percent. 105. Maximizing the completion rate and increasing intake by 100 percent would yield a more than three-fold increase in the number of nurse graduates in an even shorter period of time. The second scenario took on a more intense approach to increasing the number o f nurse graduates. Again the completion rate would be improved to 85 percent, but the increase in intake into pre-service training programs would be 100 percent, resulting in an increase o f annual graduates from 585 in 2007 to 1,800 in 2015 and constant thereafter. In terms o f the nurse workforce, this related to an estimated increase o f 3,100 nurses in 2015, and 9,600 in 2025. This effort would require a much greater increase in the number o f nurse tutors from 90 to 680. Achievements in increasing the stock o f nurses would however be negated if the attrition rate would increase from 8 percent to 24 percent. 106. Efforts to increase the output of nurses (i.e. increase completion rate to 85 percent and increase intake o f students by 50 percent and 100 percent) would still not be sufficient for the supply of nurses to meet the growing demand for nurses in 38 The Nurse Labor and Educution Markets in the English-Speakrng CARICOM Issues and Optionsfor Reform the ES CARICOM. A s presented earlier, if no policy change occurs, the gap between demand and supply would widen to 10,700 by 2025. An increase in the intake o f 50 percent and improved completion rates would result in a significant reduction in the demand-supply mismatch, however, in 2025, there would remain a shortage o f 3,500 nurses. And even in the best-case scenario where the intake would be increased by 100 percent, there would be s t i l l an estimated shortage o f 600 nurses in 2025 (Figure 8). Figure 8: Composite Projection of Supply and Demand in the Nurses Labor Market of ES CARICOM Countries in 2007-2025 20000 18000 16000 14000 8 E y. 12000 0 i t 10000 n E 3 2 8000 6000 4000 2000 0 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 -Demand -SQ Scenario 1 -m*- Scenario 2 Source: Authors' calculations based on data from country case studies, the Canadian Nurses Association (2002), the United Nations Population Division (2007), and the World Bank's W D I and GDF databases (2007) 107. With the exception o f St. Vincent and the Grenadines, the scenario analysis suggests that no country would meet its demand for nurses, even with an increase of intake by 100 percent in 2025. There i s great promise that St. Vincent and the Grenadines would meet i t s demand for nurses even as early as 2015. By 2025, a 100 percent increase in intake and improvement o f 85 percent completion rate, would result in a 50 percent surplus o f nurses. In this scenario, St. Vincent and the Grenadines would have an estimated 7.5 nurses per 1,000 population; a rate much higher than the estimated current demand o f 3.6 nurses per 1,000 population and similar to rates in high-income countries. In Jamaica, even though demand would not be completely met, efforts to increase training capacities and improve completion rates would result in a 75 percent decrease in the gap between demand for and supply o f nurses. Unfortunately, the situation in Guyana did not look as promising. Even with an intense effort to increase 39 The iVurse Labor and Education Markets in the English-Speaking CAKICOM: Issues and Options for Reform nurse output in 2025, there would be 0.9 nurses per 1,000 population; a rate far below the estimated current demand o f 2.7 nurses per 1,000 population. Figure 9: Projection o f Supply and Demand in the Five Case Study Countries for 2015and2025 6.0 I I. 5.0 c P v) $ 2 4.0 T 0.0 0 Demand 1 - Supply Note: Square boxes represent estimated demand. Line intervals show the estimated supply o f nurses ranging from the base scenario to the best case scenario. Source: Authors' calculations based on data from the country case studies, the Canadian Nurses Association (2002), the United Nations Population Division (2007), and the World Bank's W D I and GDF databases (2007) Costs and Financing Solutions for an Expansion and Strengthening o f Training Capacity 108. F o r scenario 1 we estimated that t h e costs o f expanding training capacity , and improving completion rates between 2009 and 2020 would total about US$ 17 million. Approximately U S $ 3.5 million or 20 percent would be required for investment in infrastructure between 2010 and 2013. The remaining U S $ 14 million or 80 percent would be spent on recurrent costs to improve the quality and expansion o f training capacity. Incremental recurrent costs would reach a steady state at a level o f U S $ 1.3 million annually starting in year 20 14 (Figure 10). 40 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform 109. F o r scenario 2, we estimated that t h e costs of expanding training capacity and improving completion rates over the same period would total roughly US$ 31 million. Approximately US$ 10 million or 30 percent would be spent o n capital costs between 2010 and 2013. The remaining US$ 21 million or 70 percent would be spent on recurrent costs to improve the quality and expansion o f training capacity. Incremental recurrent costs would level out at US$2.3 million annually starting in year 2014. Figure 10: Cost o f Improving and Expanding Training Capacities According to Scenario 1and 2 $6,000 7 - _ _ 0 0 0 v .- s $3,000 1 Scenano 1 ' I Scenario 2 I n l ci n l - 8 m 3 $2,000 S 8 Q $1,000 $0 I- 2008 2010 2012 2014 2016 2018 2020 2022 Source: authors' calculations based on country case study data, The Canadian Nurses Association's report "Planning for the Future: Nursing Human Resources Projections" (2002), and WDI and GDF database, World Bank (2007) 110. T o inform t h e design o f a financing model f o r the expansion of training capacity, we estimated the costs and benefits f r o m one nurse being trained in Jamaica. The underlying method allowed distinguishing to whom costs and benefits accrue; however, if costs or benefits are incurred abroad, the method did not distinguish between persons, organizations, or governments unless it was the student herself. Estimates reflected the financing policies currently prevailing for pre-service training as well as the migrating patterns observed among Jamaican nurses. 111. As benefits accrued to the student and economies abroad while costs were exclusively b o r n by t h e government o f Jamaica, n u r s e training in the E S C A R I C O M should b e financed under a model that more fairly assigns costs to those who benefit. Under current financing policies and migration patterns, we estimated that the student was the prime beneficiary amassing more than US$400,000 over her life-time (Table 20). Economies abroad would have cost savings between US$ 3,800 in the case o f Canada and US$26,000 in the case o f the U S . The government o f Jamaica would face 41 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform net costs o f U S $ 18,600. These would be the result o f training costs totaling US$ 20,400 and revenues accruing in the form o f value added tax levied o n the consumption o f services and goods paid for with remittances. The observed pattern o f costs and benefits suggested a tripartite financing model o f nurse training in the ES CARICOM, including contributions from students, local, and foreign governments. Table 20: Costs and Benefits and to Whom They Would Accrue from One Nurse Savings in training Canada Savings in training US$ 3.8 US$ 3.8 Impact o f Full Implementation o f CSME on Intra-regional Migration Flows 112. Removing barriers to entry in the context o f the implementation o f the CSME would likely result in an increase in intra-regional migratory flows o f nurses. Looking forward, our focus has been o n trends for the ES CARICOM as a whole. This perspective was well justified, given government's efforts to move towards free movement o f skills, and in particular, nurses throughout the CSME. For the same reason, the outlook would not have been complete without exploring intra-regional effects o f the planned, full-integration o f the nurse labor market. As we discussed in Section F, once barriers to entry are removed, migratory flows tend to follow gradients o f socio-economic development and income levels between countries. While these factors are not the only determinants o f the force-field in which nurses take the decision where-to-work, information presented earlier as well as the literature suggested that differentials o f these two factors across countries determine the direction as well as correlate with the scale o f migratory net-flows. Therefore, a comparison o f these two factors across the region should allow predictions about the direction and trends o f migratory net-flows once entry barriers are removed. 113. Without a regional strategy to tackle the nurse shortages facing countries as well as an agreement that governs recruitment practices, nurse migratory flows will increase in the context o f implementing the CSME and are likely to destabilize fragile supply-side equilibrium in some o f the member countries. We estimated that differentials for both socio-economic development and wages were significant across CSME member countries, suggesting that the full integration o f the domestic nurse labor 42 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Options for Reform markets will stabilize the fragile supply-side equilibriums in some countries while threaten it in others. For example, it must be expected that Barbados will experience an increase in inflows from countries in the region while Guyana will face an increase in outflows. It will be therefore important that countries develop and adopt a regional strategy to tackle the shortage facing all o f them and furthermore, that countries participating in the CSME agree on a framework that governs the recruitment o f nurses prior to adjusting legal barriers to the free movement o f nurses. Figure 11: Hourly Salaries and GDP per Capita across Selected E S CARICOM Countries $20 $20,000 $18 ., . .. . . . . .. - -. . . .. . . . . . . . . . . . .. - . . . $18,000 0 $16 $16,000 5i 0 3 8 $14 $14,000 4 t4 g;, 3 $12 $12,000 2. E 6; s 2 $10 $10,000 m T $ $8,000 _I $8 A - h 5 $6 $6,000 3 tft s $4 $4,000 8 h) u1 Y $2 $2,000 $- $0 GY JM SV G TT SL BAR c3 Hourly salary 13GDP pc (PPP) Source: Authors' calculations based on data from country case studies, kindly provided by the government o f Barbados and the World Bank's WDI and GDF databases (2007) 43 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform I. CONCLUSIONS RECOMMENDATIONS AND I n this f i n a l section, we summarize the major findings o the analyses with a focus on the f challenges facing ES CARICOM countries and review potential entry points to stabilize supply. We conclude with a summary o current reform initiatives, a comprehensive f review ofpolicy options and specific recommendations. Challenges 114. The E S C A R I C O M faces growing shortages o f nurses. Unmet needs and excess demand is evidenced through l o w nurse to population ratios and persistently high levels of vacancies. In the absence o f action on the part o f ES C A R I C O M countries, these shortages will grow as the population ages and the needs for medical care increase. 115. These nurse shortages have and will continue to have very tangible impacts that may compromise the region's ability to meet key health goals and i t s global competitiveness. The lack o f nurses in primary care will limit the delivery o f patient education that has been shown to play a critical role in preventing chronic diseases such as diabetes. Furthermore, maintaining behavior change communication efforts to reduce the spread o f HIV/AIDS as well as providing and monitoring ART treatment, all require ample human resources in the primary care health delivery system. In addition, the shortage o f nurses i s likely to impact the quality o f health services, which, in turn, i s likely to impact the ES CARICOM's attractiveness as a locale for international businesses as well as retirees. 116. The current supply-side equilibrium could be easily destabilized. Attrition rates, which appeared to be at a historic low, slightly exceed increment rates. This delicate balance could be easily destabilized through changes in the external environment. First, prime destination countries may relax entry regulations. As our analysis suggested, entry regulations in destination countries were the primary limiting factor o f emigration from the ES C A R I C O M countries. At the same time, the populations o f destination countries age and the demand for nurses i s expected to increasingly outstrip supply. Relaxation o f entry regulations by even a single large destination country, such as the US, could rapidly increase emigration levels thereby rapidly depleting the existing stock o f nurses in the ES CARICOM. Second, with the full implementation o f the CSME, increased levels o f intra-regional migration along socio- economic and wage gradients could threaten the supply o f nurses in some o f the ES C A R I C O M countries. 117. Compounding the potential o f increased outflows from the ES C A R I C O M , the Jamaica Nurse Survey showed high levels o f dissatisfaction among nurses and a lack of knowledge about logistics and opportunities for migration. We anticipate that continued or increased shortages have the ability to further dissatisfaction and t o drive emigration, which in turn will exacerbate shortages. Furthermore, with network effects strengthened through continued improvements in global communication (e.g., internet, mobile phones, and increased participation o f international nurse recruiting firms), we predict a more informed ES C A R I C O M nurse workforce who i s more cognizant o f their 44 The Nurse Labor and Education Markets in the English-Speaking CARICOM: issues and Optionsfor Refom migration options. In addition, global experiences suggest that recruitment firms, when anticipating business opportunities, have been highly capable o f overcoming these information gaps. Entry Points to Stabilize Supply 118. We estimated that approximately 95 percent o f all potential human capital was lost in the nurse education and labor markets. For every 100 qualified applicants approximately 34 were accepted (Figure 12). O f these accepted students, in turn, only 20 graduated. For a short period o f time (less in countries without bonded labor schemes) nearly all graduates worked in the local labor market and very few migrated; however, after 15 years only half o f those original graduates remained working in the local labor market. After an additional 5 years, only about a quarter o f the original graduates remained. Thus, o f an initial pool o f 100 qualified applicants, only 5 ES CARICOM trained nurses spent their full careers working as nurses in the local labor market. The dramatic nature o f this reduction simultaneously represents the challenges and significant opportunities that exist. Figure 12: Key Education Market Indicators loo Applicants z I I I B 1 5 years after Graduation Graduation 15 years after Graduation 20 years after Graduation 0 0 4 8 12 16 20 24 Time (in years) Source: Authors' calculations based on data from country case studies 45 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform C u r r e n t Efforts 119. Individual ES CARICOM countries are engaged in a variety o f efforts to increase nurse supply, upgrade the s k i l l s o f the nurse workforce, and improve nurse satisfaction. We believe that these efforts, if implemented, are appropriate in the context o f the specific challenges each individual country faces. However we also acknowledge that these plans (i) should be reviewed in light o f new comprehensive information on specific scenarios and projections for nurse shortages in each country; (ii) should be assessed for their financial sustainability, especially where policies t o scale up training programs exist; and (iii) should include viable strategies for increasing the number o f nurse tutors, as they represent a potential binding constraint to both the capacity and the quality o f nurse training programs. In addition, we believe that these plans should be examined to identify synergies and opportunities for collective regional action and, ideally, collated into a regional strategy for the ES CAIUCOM. 120. Plans to improve the quality o f training as well as upgrade the s k i l l m i x among nurses are important and necessary; however, these same plans may actually fuel nurse emigration. Along with entry regulation barriers, challenges in passing qualifying examinations currently pose a major obstacle to nurse emigration. A s shown earlier, ES C A R I C O M trained nurses o n average have lower passing rates o f the NCLEX than their U S counterparts. As the quality o f training improves, it i s likely that passing rates will also improve. Therefore, as more ES C A R I C O M trained nurses perform well o n these international qualifying exams and thus become more competitive in the global nurse labor market, the perception o f high barriers to entry will be reduced. Likewise, initiatives to upgrade training programs will produce skills that are globally even more competitively sought after, such as nurses with Bachelor and Master degrees. Policy Options to Reduce Shortages Increase completion rates 121. There a r e several strategies E S CARICOM countries can adopt to face the challenge o f nurse shortages. To meet long t e r m demand for nurses, the ES C A R I C O M must adopt one or more o f the following strategies: (i) i) Increase completion rates; ( i i i manage migration; (iv) mobilize inactive supply; increase nurse training capacity; ( i ) and (v) improve the allocation o f existing human capital. As demonstrated in Figure 12, focusing o n strategies 1, 2, and 3 are critical as they are the biggest areas o f loss. 122. W e believe that addressing completion rates may be the best entry point to immediately bolster the workforce in the region. With o n average only 55 percent o f students graduating in the region, drop outs represent a tremendous loss o f potential human resources for health. Also, these high drop-out rates represent a l o w return to public investment in education. Because many schools in the region have substantially higher completion rates, we believe that region wide improvements in completion rates are possible. 46 The Nurse Labor and Education Markets i n the English-Speaking CARICOM: Issues and Optionsfor Reform 123. Based on the findings from studies in OECD countries, we found that countries can adopt strategies to effectively address the retention o f students. Such strategies include: (i)Establishing national monitoring systems on retention (e.g., conduct and compile the results o f exit interviews for the purpose o f understanding why students drop out); (ii) providing improved information for potential students on the program recognizing that many students enter a program and only later realize that a mismatch exists between their interests and the program; ( i ) i i increasing the flexibility o f the curriculum to accommodate different schedules and interests; (iv) providing guidance to staff on retention issues to ensure that staff detect and intervene early when students are at-risk o f dropping out; (v) creating smaller learning groups and identifying peer mentors; and (vi) introducing the co-financing o f study costs by students (Stolk et a1 2007). Increase nurse training capacity 124. Given the challenges o f managing migration discussed below, increasing nurse training capacities appears to be the most viable option for meeting long term demand for nurses in the E S CAFUCOM. In other regions, such as Sub-Saharan Africa, it has been observed that the capacity o f the education system i s the binding constraint to scaling up the number o f nurses (Preker et a1 2008). Fortunately, our analysis showed that this i s not necessarily the case in the ES CARICOM. Infrastructure constraints can be relaxed with additional finances. Clinical opportunities exist in substantial excess o f what i s utilized. However, creative strategies need to be used to address the insufficient numbers o f nurse tutors. For example, ES C A R I C O M countries should consider promoting policies, many o f them under GATS, such as (i) training nurse tutors outside the region; (ii)using in-service programs offered on-line; (iii)allowing for the temporary recruitment o f nurse tutors from Canada, the UK and the US; and (iv) drawing on the diaspora to meet the needs for tutors with specific clinical skills and areas o f expertise. Manage migration 125. The concept o f managed migration i s loosely defined. In the realm o f health, it - attempts to reconcile two human rights the right to freedom o f movement and the right to access to health services. Likewise, migration o f health professionals can be seen as having both a positive (e.g. remittances, funding flows, and returned nurses with enhanced skills) and a negative (e.g. skill shortages, increased costs, and negative impacts on services and quality o f care) impact. Given this ambivalence, there appears to be substantial policy differences on efforts to manage migration, in the ES C A R I C O M as well as globally. While some countries have adopted a laissez-faire approach, others try to actively manage migration. Policy options to manage migration fall primarily into the two categories o f unilateral and bi-, multi-lateral options (Table 21). 126. Practical implementation o f these ideas has in general been difficult, technically as well as politically. Globally, well documented and evaluated systemic approaches are scarce. Regionally, a managed migration program emerged more recently and gathered support from several stakeholders. However, upon a recent review, initiatives remained largely driven by individual countries or individual organizations with little impact to date (Salmon 2007). Moreover, bilateral initiatives between source 47 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform and destination countries proved particularly difficult. A review o f a prototype temporary migration scheme between the Caribbean and Canada concluded that "In hindsight, the magnitude o f the changes recommended and the multiple agencies and interest that would be affected made it unlikely that such a radical intervention would be successful within governmental institutions that accept change slowly and incrementally" (Dawson 2005). Create barriers to migration, such as bonding schemes and citizenship taxes Ease push factors I Train for export I Leverage expatriates I I Turn brain drain into brain circulation I 1 Lower barriers to entry for health professionals I 1 Recruit from abroad I Mutual recognition agreements (of health professional qualifications) Agreements on recruitment I Agreements on twinning, staff exchange and educational support I I Codes o f Practice for international recruitment I Source: Kurowski (2004) and Buchan (2008) 127. However, the threat to the current fragile supply equilibrium in the ES CARICOM by the growing demand for nurses in prime destination countries warrants that all policy options to manage migration should be carefully revisited and explored. The following paragraphs are a first, crude attempt to do so. 128. Create Barriers to Migration: M a n y countries in the region have already adopted bonding schemes. The Jamaican Nurse Survey demonstrated that they are likely to be effective during the period o f bonding. Similarly, some countries outside o f the ES C A R I C O M have imposed a tax o n i t s citizens living abroad or asked them to reimburse the government for the loss o f investment in their education (Dolvo 2005). They did this in hopes to potentially deter would-be migrants as well as to raise revenues. The effectiveness o f these strategies is yet to be determined. Alternative strategies available to other countries (such as training in local languages to increase the costs o f migration) are not viable in the ES CARICOM. 129. Ease push factors: The literature suggests that beyond increasing wages to decrease the differential between source and destination countries, there are important professional, social, economic, and political factors that if changed can limit migration. 48 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Optionsfor Reform While a number o f countries are already engaged in refurbishing facilities and offering further in-service training opportunities, additional opportunities should be explored. 130. T r a i n for export: Globally and regionally, some countries explicitly endorsed migration and scaled up their training capacities to `train for export'. Alternatively, the literature suggests that if barriers to entry into the nurse education market are lowered, the same results can be achieved through private sector investment. The literature further suggests that training for export eases shortages in source countries (Clemens et a1 2007). 13 1. Leverage expatriates: Multilateral organizations have developed tools to help leverage Diaspora efforts to support their home countries (Kurowski 2004). Given the high ratio between ES C A R I C O M nurses abroad and at home, the ES C A R I C O M i s well positioned to try, for example, to use expatriate volunteers to support training systems. 132. Turn brain drain into brain circulation: Overall, relocation programs, such as the Reintegration Program o f Qualified African Nationals have had little success (Marchal & Kegels 2003). However, the Jamaica Nurse Survey indicated that 79 percent o f migrant nurses trained in the ES C A R I C O M intend to return home. Though only half o f them intended to work as nurses at home, creating the opportunity for these individuals to return and work i s an opportunity that should be explored. 133. L o w e r barriers to entry for health professionals: The full implementation o f the CSME requires abolishing all barriers to entry for nurses. Likewise, barriers could be lowered for health professionals from outside the CSME. Once barriers are lowered, it could be expected that immigration sets in from countries with lower levels o f socio- economic development and wages. 134. Recruit f r o m abroad: Given the global shortage o f nurses and, in particular, ethical considerations involved in recruiting nurses from lower income countries which also experience shortages, we do not recommend the recruitment o f foreign nurses as a mainstay for meeting demand for nurses. However, recruitment o f foreign nurses, including nurses from OECD countries, may be used selectively to bring into the ES C A R I C O M highly specialized nurses, in particular nurse tutors. ES C A R I C O M countries have indeed begun recruiting nurses and nurse tutors from countries such as Cuba, Nigeria, the Philippines, and India. Lessons should be learned from both the successes and mistakes o f these recruiting efforts in order for ES C A R I C O M countries to gain the most out o f these efforts. 135. Mutual recognition agreements: Mutual recognition agreements focus o n ensuring that an individual nurse meets minimum, mutually agreed, educational and professional standards. They are designed to facilitate the mobility o f professionals in regulated professions such as nurses. Mutual recognition has been achieved among the majority o f ES C A R I C O M countries and with the UK. Agreements may be expanded to countries that may serve as potential sources o f migrants to the ES CARICOM. 136. Agreements on recruitment: Agreements on recruitment, normally between governments, set out approaches to facilitate the international f l o w o f nurses. They may cover specifics such as numbers and time periods or may be broad based "enabling" mechanisms. Agreements on recruitment may have the advantage o f allowing the monitoring of migratory flows and, subject to their design, crowding out individual 49 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform initiatives. As discussed above, C A R I C O M attempted to develop a prototype temporary migration scheme with Canada, however, the process has become stalled. 137. Agreements o n twinning, staff exchange, and educational support: Such agreements, between governments and/or individual organizations, govern primarily the structured temporary movement o f staff based on needs and career development opportunities, including funding related to temporary movement. In the ES CARICOM, there i s some experience with such approaches, such as an agreement between Grenada and Aruba as well as several ES C A R I C O M countries and Cuba. 138. Codes o f practice: Codes o f practice cover principles and policies to facilitate effective international recruitment. They also set out some ethical requirements. For example, to minimize the negative impact o f migration, there should be no active recruitment o f designated countries. To our knowledge, ES C A R I C O M countries have no immediate experience with this approach. As we discussed earlier, the full implementation o f the CSME i s likely to result in increased migration o f nurses within the region. While supporting the rights o f nurses to migrate within the region, there i s also a need to limit aggressive recruitment o f nurses from poorer countries. Consequently, a regional approach to govern recruitment should be explored. Other policy options 139. Mobilize inactive supply. Although mobilizing the inactive supply has been an effective means o f meeting health worker shortages in other countries, our analysis presented in Section E showed that mobilizing the inactive supply o f nurses represented the least viable o f the policy options (Vujicic & Evans 2005, OECD 2007). Survey data suggested that among non-migrants almost all worked, and all within the field o f nursing. 140. Improve the allocation o f existing human capital. As we demonstrated in Section E, the majority o f nurses worked in secondary and tertiary settings. In order to more effectively confront emergent chronic conditions in the region, more nurses need to be trained and deployed within primary care settings. Our research showed that countries performing best in this regard were the ones that have established specific primary care nurse cadres, and were monitoring and actively recruiting for these positions. 141. Shifting tasks to lower skilled workers. T o date the literature o n task shifting has largely focused on using task shifting as a strategy to reduce physician workload, especially in the context o f the HIV/AIDS pandemic. Although some HIV/AIDS related tasks have been identified, there i s little evidence and experience with task shifting from nurses to lower skilled health worker in more general. However, with the demographic and epidemiological shift occurring in the ES CARICOM, the potential for shifting tasks from nurses to lower skilled workers or to patients themselves will be important to keep in mind as part o f a comprehensive human resource strategy (WHO 2008). Financing the Strengthening and Scaling-up o f Nurse Training 142. Strengthening and scaling-up nurse training may require adopting tripartite financing arrangements. Strengthening and scaling-up nurse training requires substantial financial outlays both for capital and operating expenses. This calls into 50 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform question the high rate o f subsidization o f the current system, in particular, in the face o f a deteriorating global financial and economic environment. Survey data indicated that nurses reported a willingness to pay a significant share o f their training costs, in particular, if l o w interest loans were available. In addition, key informants indicated that the current level o f subsidization may actually lend i t s e l f to some students undervaluing their training who are therefore less likely to complete their studies. Moreover, migratory outflows represent direct cost-savings for the destination countries. Hence, a tripartite financing model with contributions from local and destination country governments as well as students appears most sustainable and just. 143. The impact o f new sources o f funding should be leveraged by introducing innovative financing arrangements that facilitate private sector investment. Historically, ES C A R I C O M governments have both financed and provided nurse training. Exploring new sources o f funding to expand nurse training capacity should include options that promote adopting new funding arrangements that bolster private investment. As discussed before, evidence from Africa suggested that diversification in the education market for health professionals helped to maintain local stocks in the presence o f substantial migratory outflows (Clements 2007). Steps in this direction have been taken by some o f the ES C A R I C O M governments as they reimburse the tuition that students pay that are enrolled in private institutions. Further opening up the education market for nurses in the ES C A R I C O M could, for example, be facilitated by pooling resources and buying rather than providing services. Recommendations 144. As noted earlier, a l l case study countries were engaged in activities and/or had plans to improve t h e quality o f n u r s e education and increase t h e number o f nurses trained. Consultations w i t h individual countries should take place to assess these plans. In the course o f our research, we learned that monitoring and evaluation data of the n u r s e labor and education markets were scarce. Given t h e potential fragility of the ES C A R I C O M n u r s e labor market, i t i s critical that countries more closely monitor n u r s e labor market (e.g. vacancy levels, skill-mix, and attrition including migration) and n u r s e education market (e.g. student to tutor ratios, intake rates, and completion rates). 145. Ultimately, we believe that a false dichotomy exists between choosing to focus on increasing nurse training capacity versus focusing on managing migration; in fact, both must b e done jointly and immediately. I f the ES C A R I C O M i s to address current and future nurse shortages, b e increasingly protected against a large outflow o f nurses and simultaneously recognize an individual's right to freedom o f movement, t h e ES C A R I C O M must both increase the number o f n u r s e graduates and manage migration. 146. A regional effort to strengthen and scale-up nurse training i s critical t o success. The scarcity o f tutors, t h e intra-regional distribution o f health care capacity and t h e limited number o f institutions offering higher degrees warrant regional coordination. Ideally, country initiatives would be collated into a single, regional strategy. Moreover, t h e implementation of t h e C S M E and associated 51 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform increases in intra-regional m i g r a t i o n requires a coordinated a p p r o a c h t o govern the nurse education and l a b o r markets. 147. Managing migrations requires reaching o u t t o destination countries, the goal b e i n g t o establish a n d agree o n annual flows, cost-sharing arrangements f o r necessary investment in nurse training capacity and technical support. Such agreements w o u l d b e in t h e best interests o f b o t h source and destination countries, as they m a k e flows m o r e transparent a n d predictable and facilitate w o r k f o r c e m o n i t o r i n g and planning o n b o t h ends. I t w o u l d h e l p destination countries that struggle t o achieve self-sufficiency in reconciling i m m i g r a t i o n policies with foreign policies. However, as f o r efforts t o strengthen a n d scale-up training capacity, o n l y a regional initiative i s l i k e l y t o succeed. G i v e n t h e discrepancies between t h e sizes o f workforces in t h e E S CARICOM v i s - h i s Canada, t h e UK, and t h e US, o n l y a j o i n e d approach o f E S CARICOM countries w o u l d create a win-win situation. M o r e recent experiences o f attempts t o manage m i g r a t i o n suggest that s m a l l scale initiatives d o n o t sustain t h e interest o f destination countries (Dawson 2006). 148. E f f o r t t o strengthen and scale-up t r a i n i n g capacity and manage m i g r a t i o n should b e combined with f i n a n c i n g r e f o r m s that m o r e fairly assign costs t o those w h o benefit. A t r i p a r t i t e f i n a n c i n g m o d e l appeared t o b e m o s t a p p r o p r i a t e with contributions f r o m governments in t h e ES CARICOM, f r o m governments in destination countries and students themselves. 149. Collectively, t h e discussed actions have t h e p o t e n t i a l t o stabilize t h e delicate d e m a n d a n d supply e q u i l i b r i u m o f n u r s e s in t h e E S CARICOM. S w i f t corrective measures a r e o f u t m o s t importance. 52 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform LABORD EDUCATION THENURSE AN MARKETS E E G I HS E KN IN TH N LS - P A I G CAMCOM: ISSUESFOR REFORM N A D OPTIONS Human Development Department Caribbean Country Management Unit Latin America and the Caribbean Region June 2009 SUPPLEMENT TO MAIN ANNEXES REPORT: Annex A: Statistical Data Annex B: Methodology Annex C: ES CARICOM Case Country Studies Annex D: OECD Case Country Studies Annex E: Jamaican Nurse Labor Survey 53 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform ANNEX STATISTICAL A: DATA Introduction The statistical data i s presented in this annex as a series o f Tables. The initial series o f Tables (Table A1 to Table AS) contain the core statistical data depicted in the figures presented in the main report. These Tables are cross referenced with their respective figures. Some o f the Tables (Table A9 to Table A16) also provide detailed statistical data from which statements and conclusions in the main report were inferred. These Tables, along with the Tables in the main report and in the `Jamaican Nurse Labor Survey' section, contain the core figures underlying the arguments and recommendations made in the main report. The Tables presented in this annex also supplement the data presented in the Tables and Figures o f the main report. Table Al: GDP per Capita PPP, Supply o f nurses per 1,000 population, and Demand per 1,000 population in the Case Study Countries I Jamaica I $7,189 I 1.06 I 1.43 I St. Lucia $9,335 2.2 2.41 St. Vincent and the $6,798 2.55 2.96 Grenadines Trinidad and Tobago $15,387 1.79 2.73 Source: authors' calculations based on country case study data and W D I and GDF database, World Bank (2007) Note: calculations for Nurse per 1,000 population includes all RegisteredNurses and Midwives Note 2: The Table provides data for Figure 1 and Figure 2 o f the report. Table A2: Inflow o f ES CARICOM Nurses to Canada, the UK, and the USA in 2002-2006 Source, authors' calculations based on Nursing Council Licensure Examination (2002-2006), Nursing and Midwifery Council (2005), and Canadian Institute for Health Information (2006) Note: The Table provides data for Figure 3 o f the report 54 The Nurse Labor and Education Markets in the English-Speakzng CARICOM: Issues and Optionsfor Reform Table A3: GDP per capita PPP, Comparative GDP Per Capita as a Percentage o f Belize $6,253 36.9% 2.6% 15.0% - - Dominica $7,229 42.6% 2.8% 17.3% - - 1 Grenada 1 $7,052 I 41.6% I 1.6% 1 16.9% I - I - / 1 Guyana I $2,563 I 15.1% I 5.4% 1 6.1% 1 $6.86 I 36% 1 I Jamaica 1 $6,112 I 36.0% I 3.9% I 14.6% I $6.98 1 36% I St. Lucia $8,879 52.4% 2.4% 2 1.2% $10.86 57% St. Vincent and the $6,43 1 37.9% 2.3% 15.4% $9.01 47% Grenadines Trinidad and $18,818 111.0% 0.5% 45.0% $10.71 56% Tobago Source: authors' calculations based on country case study data, US Census data and WDI and GDF database, World Bank (2007) Note: The Table provides data for Figure 4 and Figure 5 o f the report. Table A4: U S NCLEX Pass Rates bv Countrv o f Training in 2000-2005 Countries U NCLEX pass rates S Guyana 42.3% I St. L u c i a I 43.2% I Barbados 47.1% Grenada 50.0% St. Vincent and the Grenadines 52.6% I Dominica I 55.6% I Trinidad and Tobago 56.5% CARICOM 58.5% Belize 65.4% I Jamaica I 65.7% I USA 80.1% 55 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Table A5: Composite Projections o f Demand, Base Case Scenario, Scenario 1, and Scenario 2 in the Nurses Labor Market o f ES CARICOM Countries in 2007-2025 2008 11485 7796 7796 7796 2009 11699 7765 7765 7666 2010 11913 7736 7780 7496 201 1 12124 7710 8027 748 1 2012 12334 7686 8539 7574 2013 12545 7664 9265 7728 2014 12755 7643 10147 7870 2015 12966 7625 11070 7890 I 2016 I 13434 I 7607 I 11979 I 7807 I I 2017 I 13810 I 7591 I 12816 I 7739 I I 2018 I 14255 I 7577 1 13587 I 7684 I 2019 14821 7563 14297 763 8 2020 15385 755 1 14952 7600 I 202 1 I 15922 I 7539 I 15554 I 7570 I 2022 16561 7528 16109 7545 2023 17202 7519 16620 7524 2024 17766 7510 17091 7507 2025 18159 7501 17524 7493 Source: Authors' calculations based on country case study data, the Canadian Nurses Association's report "Planning for the Future: Nursing Human Resources Projections" (2002), United Nations Population Division (2007), and WDI and GDF database, World Bank (2007) Note: `Demand', `Base Case Scenario', 'Scenario l', `Scenario 2', and `Scenario 3' are in No. o f Nurses. Note 2: The Table provides data for Figure 7 and Figure 8 o f the report. Table A6: Projection o f Supply and Demand (per 1,000 population) in the Nurses I Saint Lucia 1 Saint Vincent & Grenadines 1 3.2 1 3.8 I 3.6 I 6.0 I Trinidad & Tobago 3.1 2.0 3.7 2.5 56 The Nurse Labor and Education Markets in the English-Speaking CARICOM. Issues and Optionsfor Refo1.m Table A7: Cost o f Improving and Expanding Training Capacities According to Scenario 1 and 2 2010 $562 $562 201 1 $1,195 $1,828 I 2012 I $2,46 1 I $3,728 I 2013 I $3,140 I $5,085 2014 $1,333 $5,772 2015 $1,333 $2,286 I 2016 I $1,333 I $2,286 2017 $1,333 $2,286 2018 $1,333 $2,286 I 2019 I $1,333 I $2,286 I 2020 I $1,333 I $2,286 Source: authors' calculations based on country case study data, The Canadian Nurses Association's report "Planning for the Future: Nursing Human Resources Projections" (2002), and WDI and GDF database, World Bank (2007) Note: The Table provides data for Figure 10 o f the report. Table A8: Hourly Salary and GDP per Capita PPP across Selected ES CARICOM Countries Guyana $6.86 $2,563 Jamaica $6.98 $6,112 St. Vincent and the Grenadines $9.01 I $6,431 I Trinidad and Tobago $10.71 I $18,818 I St. Lucia $10.86 1 $8,879 I Barbados $15.56 1 $16,957 1 Source: authors' calculations based on country case study data and W D I and GDF database, World Bank (2007) Note: The Table provides data for Figure 11 o f the report. 57 The Nurse Labor and Education Markets in the English-Speaking CARICOM. Issues and Options for Reform 1 Intake/Applicants I 38.8% I 26.2% I 37.5% 1 34.2% I 1 Output / Intake I - I - I - I 55.8% I Source: authors' calculations based on country case study data Table A10: Output/ Input Ratios in the Nurse Education Market for the years 2004- 2006 I JM I 101 I 69 I 68% I I SL I 74 I 65 I 8 8% I SVG 200 89 45% TT 457 263 58% Total 1078 60 1 56% r a Tl d e b - , - and Vacancies in the Nurse Labor Market 1 Supply I 405 1 2,835 I 365 I 305 I 2,380 I 6,290 1 7,995 1 I Vacancies 1 470 1 970 1 35 I 50 1 1,240 1 2,765 I 3,510 1 Demand 875 3,805 400 355 3,620 9,055 11,505 Supply (Per 1,000 0.55 1.06 2.20 2.55 1.79 1.25 - population) Demand (per 1,000 1.18 1.43 2.41 2.96 2.73 1.80 - population) 58 The iVurse Labor and Education Markets in the English-Speaking CARICOM: h u e s and Optionsfor Reform 0 235 0 5 0 240 Others (0.0%) (8.3 Yo) (0.0%) (1.6%) (0.0%) (3. so/) 405 2,835 365 305 2,380 6,290 Total (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) Nurses per 1,000 0.40 0.80 1.81 1.92 1.60 1.01 population, care Nurse per 1,000 o.55 1.06 2.20 2.55 1.79 1.25 population, total Source: authors' calculations based on country case study data 59 The h'urse Labor and Education Markers in the English-Speaking CARICOM: Issues and Optionsfor Reform Table A13: V ,abor M a r l t Care, secondary and tertiary level, general nurses (A) 220 (46.8%) 1 - - 765 (61.7%) Care, secondary and tertiary 75 level, (3 0.9%) - (6.0%) specialized nurses (B) 365 25 30 840 Subtotal A+B - (7 7.7%) (7 1.4%) (60.0%) (67.7%) Supervision, Administration, 60 5 250 Management (12.8%) - (10.0%) (20.2%) (C) Subtotal 425 875 35 35 1090 2460 A+B+C (90.4%) (90.2%) (100.0%) (70.0%) (87.9%) (89.0%) Care, primary 25 90 0 10 90 215 level (5.3%) (9.3%) (0.0%) (20.0%) (7.3%) (7.8%) 20 5 0 5 60 90 Education (4.3%) (0.5%) Y) (0.O O (10.0%) (4.8%) (3.3%) 0 0 0 Others (0.0%) (0.0%) (0.0%) (0.0%) (0.OYO) (0.0%) 470 970 35 50 1240 2765 Total (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) (1 00.0?40) 1 Vacancy ratio 53.7% 25.5% 8.8% 14.1% 34.3% 30.5% Vacancies per 1,000 0.64 0.36 0.21 0.42 0.93 0.55 population Source: authors' calculations based on country case study data 60 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Table A14: Attrition rate, number o f Nurses lost through Retirement, Death & (YO) (YO} (%) (YO} {%>) 7 14 10 6 37 Retirement (9.3%) (7.7%) (3 5.7%) (2 8.6%) (12.1%) Death & 1 3 0 1 5 Disability (1.3%) (1.6%) (0.0%) (4.8%) (1.6%) 55 0 4 0 59 Migration (73 .3 yo) (0.0%) ( 14.3yo) (0.0%) (19.2%) Not 12 166 14 14 206 specified (16.0%) (90.7%) (5 0.0%) (66.7 %) (67.1%) 75 183 28 21 307 Total (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) Source: authors' calculations based on country case study data 61 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Table A 1 5 Increments for thc year ES CY JM SL SVG Population 739,472 2,654,500 164,791 119,137 1,323,722 5,001,622 6,218,189 (2005) 2006 Net Increment (Pre-service Program in General Nursing) 33 245 T-T-T 146 469 585 N e t Increment (pre-service in GN/Total 8% 9% 6% 8% 6% 5% Established Posts)* Net Increment (Pre-service 0 0 25 25 35 Program other**) I N e t Increment (pre-service in others/Total 0% 0% 0% 0% 1% Established 1 , , Posts)* Gross Increment (pre+in-service 48 296 21 24 Programs)* * * L 04-2006 data average, average % Gross Increment re+in-service 5Y O 6% - I I I L 02-2006 7ata average Net IncremenUIntake 51% 54% 88% 3 0% 58% 55% Ratio (for Pre- service program) Qualified Applicants/Intake Ratio (for Pre- 66% 56% 130% 41% 75% service program, public) Qualified High School Students 4697 14943 18606 (for Pre-service program) Source: authors' calculations based on country case study data and W D I and GDF database, World Bank (2007) * Total Established Posts= Total Workforce + Vacancies ** Pre-Service Program Other: Only available in TT and it i s called Associate Degree o f Science in Psychiatric Nursing *** N o information on the number o f graduates from in-service diploma and certificate programs 62 The iVurse Labor and Education Markets in the English-$leaking CARICOM: Issues and Options for Reform Guyana 739,472 405 470 0.54 33 8.1% Jamaica 2,654,500 2835 970 0.25 245 8.6% St. Lucia 164,79 1 365 35 0.09 21 5.8% St. Vincent and the 119,137 305 50 0.14 24 7.9% , Grenadines Trinidad and ,323,722 2380 1,240 0.34 146 6.1% Tobago Total (5 case study 5,001,622 6290 2,765 0.3 1 469 7.5% countries) Source: authors' calculations based on country case study data and WDI and GDF database, World Bank (2007) 63 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform ANNEXB: METHODOLOGY ANNEX Introduction In this annex, we provide a detailed description o f methodology that we used for the analyses in the report. Research efforts included five main streams o f work: Case studies in the ES CARICOM; case studies in selected OECD countries; a nurse labor survey among graduates from Jamaica; supply and demand projections for the ES CARICOM, and literature reviews (Table1 o f the report). Table B1: Main Research Activities Stream of Work Purpose _I-.__ -_ Case studies o f ES CARICOM - Determine characteristics and countries (Guyana, Jamaica, St. schools, hospital; census trends o f the nurse labor and Lucia, St. Vincent and the education market o f the English- Grenadines: and Trinidad and speaking C A R I C O M Tobago Case studies o f selected OECD Census, nursing registration, and Determine stocks, flows and countries (Canada, U.K., USA) nurse examination data driving forces o f migratory flows from the ES CARICOM to main destination countries Jamaica Nurse Survey Survey among Jamaican nurse ldentifj and determine the role graduates (1980, 1990,2000,2005) o f factors driving labor and education market behaviors o f ES CARICOM nurses Supply and demand projections Case studies o f ES CARKCOM, Project supply and demand for for the ES CARICOM Jamaica N u r s e Survey, nurses in the ES CAFUCOM and demographic projections (LJN carry out scenario analyses Population Division 2006), and Canadian nurse utilization patterns (Canadian Nurses Association 2002') Structure o f MethodologyAnnex The following section, ES CARICOM Case Country Studies, provides methods applied to analyze the current situation o f the ES C A R I C O M nurse labor and education market. Sections E, F and G o f the main report present some o f the findings from this study. I t i s followed b y a section, OECD Case Country Studies, which allowed us to better understand the ES C A R I C O M nurse labor market and i t s interactions with the global nurse labor market. The findings o f this section can be found in Section F and H o f the main report. The Jamaican Nurse Labor and Education Survey Section describes the methodology we applied to identify the factors that determined labor and education market behaviors 64 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform o f ES C A R I C O M nurses. Some o f the findings derived from this survey are presented in Section E, F and G o f the main report. The Supply and Demand Projections for the ES CARICOM Section presents methodology to project the nurse labor market. Section H o f the main report provides the major findings o f the analyses. ES CARICOM Case Country Studies We examined the nurse labor and education markets o f five ES C A R I C O M countries: Guyana, Jamaica, St. Lucia, St. Vincent and the Grenadines, and Trinidad and Tobago. We worked in close collaboration with Ministries o f Health, Ministries o f Education, nursing schools and councils, and public and private health care facilities. Primary data was collected by in-country consultants between M a y and December 2007. The information collected in these case country studies served three purposes: 1) to provide a comprehensive picture o f the ES C A R I C O M nurse labor and education markets; 2) to compile contact information to be used to conduct a nurse labor survey; and 3) for analysis o f forecasting the supply o f and demand for nurses in the ES C A R I C O M nurse labor market. Nurse Labor Market In order to fully understand the nurse labor markets o f the five case study countries, we examined the supply o f and demand for nurses in the labor market. In particular, we analyzed the active supply o f nurses, increments (which will be discussed in greater detail in the nurse education market section), attrition, and vacancies. Since there was limited publicly available data, we collected primary data. Data was collected from 1) Human Resource departments and Head Offices o f Nursing Divisions o f Ministries o f Health, universities, and hospitals at both the national and regional levels; 2) interviews with Ministries o f Health, universities, and hospital officials; and 3) government and hospital records. We first identified specific nurse cadres. N u r s e cadres were categorized by their specific roles and specialties in the health care delivery system (e.g., staff nurse, charge nurse, public health nurse, or nurse tutor). I t should be noted that nursing titles, positions, and j o b descriptions differ in each country. Therefore, identifying and outlining nurse cadres were important for conducting cross-country analyses. We developed a l i s t o f cadres for each case study country that included information o n the perquisite requirements o f educational and occupational experience needed for each cadre, and the common work setting o f each cadre (e.g., primary care, secondary care, tertiary care, education, and administration). In terms o f the active supply, we collected data o n indicators such as the total established nurse positions (number o f "budgeted" positions) and number o f filled positions. We also collected data on the inflow o f foreign nurses into the local nurse labor market. This data was collected by cadre, type o f academic and/or professional degree, and sector o f employment (public or private). In terms o f attrition, we collected data on indicators such as the total annual attrition from the nurse labor market broken down b y irreversible 65 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform (death and disability) and reversible (retirement, resignation, migration, and other causes) factors. This data was collected by cadre. In terms o f vacancies, we collected data on indicators such as the number o f unfilled vacancies (number o f budgeted positions minus number o f filled positions). This data was collected by cadre, type o f academic and/or professional degree, and sector o f employment (public or private). The abovementioned data was collected for 2002-2007. In cases where data was not available for that time period, it was collected up to the last available year. I t should be noted that estimates o f the active supply, attrition, and vacancies may be understated since information was not collected from all hospitals (particularly data collection from private hospitals was limited), data o n attrition was not available or up to date from all hospital nurse registries, and definitions o f vacancies were inconsistent. We examined the different salary ranges for nurse cadres in the public sector in order to analyze wage differentials between the five case study countries. We also analyzed data o n the wage differentials between non-migrant ES C A R I C O M trained nurses, migrant ES C A R I C O M trained nurses and OECD trained nurses. Data was collected based on salary ranges and did not include benefits. In order to fully understand the net income o f R N s , information o n income tax and other expenses (e.g., social security and national insurance scheme) was collected. I t should be noted that data o n income tax and other expenses was limited to Jamaica and St. Vincent and the Grenadines. In addition to the collection o f primary data, we also examined current government policies o n the nurse labor market. In particular, we looked at specific policies and strategies to increase the nurse workforce, reduce attrition and manage migration o f ES C A R I C O M trained nurses. We identified policies and strategies such as recruiting foreign nurses, providing financial incentives for nurses (wage and fringe benefits), improving the work environment, and improving work and career development opportunities. Information was gathered from government documents, published studies, administrative databases, and meetings with stakeholders (Ministry o f Health officials and nursing school administrators). Nurse Education Market In order to fully understand the nurse education market o f the five case study countries, we examined the supply and demand o f the nurse education market. In particular, we analyzed the applicant pool, the intake o f students, and the graduation output. Data was collected from Ministries o f Education, nursing schools, and nursing registries o f nursing councils. We first identified all nursing schools in the five case study countries. Also, we identified the types o f nursing degrees and programs (pre-service' and in-serviceS) offered, the duration o f these programs, and the various types o f financing mechanisms (public, autonomous public, and private) in the five case study countries. W e examined specific nurse licensure requirements and registry procedures in the five case study countries. ' Pre-service degrees are designed for students who do not have a license to practice as a registered nurse. t: In-service degrees are designed for registered nurses who wish t o continue their education. 66 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform In terms o f the applicant pool, we collected data o n the number o f high school graduates that had the minimum qualifications for entry into nurse training programs and the number o f actual applicants to nursing programs. In terms o f the intake o f students, we collected data on the number o f applicants who were accepted into nursing programs and the number o f approved positions available in the schools. Since student enrollment was directed by government policies in some countries and infrastructure andor staffing capacity in others, we collected data on training capacity and the possible bottlenecks to increase training capacities. In terms o f gradation output, we collected data o n the number o f graduates who completed pre- and in-service programs. Data was collected up to the last available year. In order t o calculate the unit cost to train 1 ES C A R I C O M nurse, we collected relevant cost information. In particular, we identified tuition costs, total annual public expenditure o f nurse training including capital and recurrent costs, amount o f stipends given to students, availability o f scholarships, and availability o f loans for nursing education. In addition to the collection o f primary data, we also examined current government policies on the nurse education market. In particular, we looked at specific policies and strategies to reform nurse education and increase the nurse workforce by increasing training capacities. We identified policies and strategies such as increasing the public expenditure for nurse education (capital cost), providing financial incentives for nurse students, increasing the annual intake o f nurse students, increasing the number o f nurse tutors (e.g., recruiting foreign nurse tutors), increasing the number o f nursing programs, improving curricula and pedagogical approaches to nurse education (e.g., using online teaching resources), and improving completion rates. Information was gathered from government documents, published studies, administrative databases, and meetings with stakeholders (Ministry o f Health officials, nursing councils, and nursing school administrators). Database o graduates o nursingprograms f f For each case study country, we created a database containing the contact information o f all the nurse graduates from 2 selected public nursing schools and who graduated in the year 1980, 1990, 2000, and 2005. I t should be noted that there i s only one nursing school in both St. Lucia and St. Vincent and the Grenadines. Also, due to policy decisions on nurse education in Trinidad and Tobago, there were no nurse graduates in 1980; therefore, data was collected for 1983. Contact information included name, address, country o f residence, and telephone number. Data was collected from nursing schools' administrative records and nursing councils' records o f RNCRE (except in Guyana where data was collected from the national nursing exam records). Data was further validated through administrative databases, nursing school administration and registrar offices, nursing association databases, and key informant interviews with officials from nursing councils and directors o f nursing schools. The contact information was compiled into a database for use in the nurse labor and education survey. 67 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform OECD Case Country Studies In order to better understand the ES CARICOM nurse labor market and i t s interaction with the global nurse labor market, we examined both the stock and inflow o f ES CARICOM trained nurses to prime destination countries: Canada, the UK, and the US. S This information also shed light on migratory patterns o f E CARICOM trained nurses to these destination countries. Census data was used to examine stock o f ES CARICOM trained nurses in these destination countries. National nurse registration data was used to estimate inflow o f ES CARICOM nurses to these destination countries. Stock o ES CARICOM trained nurses in selected OECD countries f Canada The 2001 Canadian Census was used to estimate the stock o f ES CARICOM nurses. This data came from an approximate 2.7% sample o f the Canadian census. Data was weighted using individual weights. For this report, the ideal measure o f stock o f ES CARICOM trained nurses in destination countries would include all persons trained as a nurse in the ES CARICOM, regardless of current occupation or employment status. Brain drain can be estimated using this measure o f stock. In terms o f estimating the stock o f ES CARICOM trained nurses in Canada, the Canadian Census was limited in that data on the location o f nurse training was not available. Therefore, our analysis identified foreign-educated nurses using four variables: ethnicity; immigration status; age at the time o f migration; and current occupation. Specifically, stock data included all persons who reported their ethnicity as "Caribbean", who were not born as a Canadian citizen, who immigrated to Canada after the age o f 20, and whose occupation was a registered nurse. Another limitation o f the Canadian Census was that the ethnicity data was not country specific and only included the classification o f "Caribbean". In order to estimate the stock o f ES CARICOM trained nurses, we adjusted the stock o f Caribbean trained nurses in Canada by the percentage o f ES CARICOM nurses in the U S (number o f ES CARICOM nurses out o f all Caribbean nurses in the US)(Equation 1). In addition, we needed to adjust the stock data to account for the significant percent o f ES CARICOM immigrants who trained as a nurse in Canada. We did this by adjusting the stock o f ES CARICOM nurses in Canada b y the proportion o f the number o f ES CARICOM nurses trained in the U S out o f the total ES CARICOM nurses (Equation 2). It should be noted that data on whether ES CARICOM trained nurses who are living in Canada are currently working as a nurse i s not available. It should also be noted that the presented stock estimates may underestimate the true number o f ES CARICOM trained nurses in the prime destination countries. 68 The Ntrrse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform PI: percentage o f ES CARICOM nurses in the U S out o f all Caribbean nurses in the US Pz: percentage o f ES CARICOM nurses trained in the U S out o f the total ES CARICOM nurses S,: Caribbean nurses in Canada ES CARICOM nurses in Canada =S,xP1 .... (Equation 1) ES CARICOM trained nurses in Canada =ES CARICOM nurses in Canada x (l-P2) .... (Equation 2) UK The 2001 UK Census was used to estimate the stock o f ES CARICOM nurses. This data was commissioned from the Office for National Statistics (ONS). The Census, conducted by the ONS, i s a ten-yearly compulsory survey o f all people and households in England and Wales in the UK. The most recent census was conducted in 2001, For this report, the ideal measure o f stock o f ES CARICOM-trained nurses in destination countries would include all persons trained as a nurse in the ES CARICOM, regardless o f current occupation or employment status. Brain drain can be estimated using this measure o f stock. In terms o f estimating the stock o f ES CARICOM trained nurses in the UK, the UK Census was limited in that data on the location o f nurse training was not available. Therefore, our analysis identified foreign-educated nurses using three variables: place o f birth; immigration status; and current occupation. Specifically, stock data included all persons who reported their place o f birth in an ES CARICOM country, who were not born as a UK citizen, and whose occupation was a registered nurse. Since data on age at the time o f migration was not available, we were unable to directly estimate the stock o f foreign-educated nurses. To compensate for this, we applied the percentage o f ES CARICOM born nurses who migrated as an adult out o f all ES CARICOM nurses in the U S to the foreign-born stock in the UK (Equation 3). In addition, we needed to adjust the stock data to account for the significant percent o f ES CARICOM immigrants who trained as a nurse in the UK. We did this by adjusting the stock o f ES CARICOM nurses in the UK by the percentage o f the number o f ES CARICOM nurses trained in the U S out o f the total ES CARICOM nurses (Equation 4). It should be noted that data on whether ES CARICOM trained nurses who are living in the UK are currently working as a nurse i s not available. It should also be noted that the presented stock estimates may underestimate the true number o f ES CARICOM trained nurses in the prime destination countries. 69 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform P3: percentage o f ES CARICOM nurses who i s adult migrant out o f all ES CARICOM nurses in the U S P2: percentage o f ES CARICOM nurses trained in the U out o f the total ES CARICOM S nurses SUK: ES CARICOM born nurses in the UK E S CARICOM nurses who i s adult migrant in UK 'SUK x p3 .... (Equation 3) ES CARICOM trained nurses in Canada =ES CARICOM nurses who i s adult migrant in UK x (l-Pt). . .. (Equation 4) us S The 1980, 1990, and 2000 U Censuses were used to estimate the stock o f ES CARICOM nurses in the U S . This data came from an approximate 5% sample o f the U S census. Data was weighted using individual weights. For this report, the ideal measure o f stock o f ES CARICOM trained nurses in destination countries would include all persons trained as a nurse in the ES CARICOM, regardless o f current occupation or employment status. Brain drain can be estimated using this measure o f stock. In terms of estimating the stock o f ES CARICOM trained nurses in the US, the U S Census was limited in that data on the location o f nurse training was not available. Therefore, our analysis identified foreign-educated nurses using four variables: place o f birth; immigration status; age at the time o f migration; and current occupation. Specifically, stock data included all persons who reported their place o f birth in an ES CARICOM country, who were not born as a U S citizen, who immigrated to U S after the age of 2 1, and whose occupation was a registered nurse. From this information, we were able to directly estimate the stock o f ES CARICOM trained nurses in the U S . In addition, we needed to adjust the stock data to account for the significant percent o f ES CARICOM immigrants who trained as a nurse in the US. Two different methods o f estimating stock o f ES CARICOM trained nurses are presented here. The standard method o f calculating the number o f foreign-educated nurses i s to identify foreign-born nurses who migrated after the age o f 21. This method i s the most commonly used to analyze brain drain. However, this method does not exclude those who became a nurse after immigrating to the U S . In order to obtain better estimates o f brain drain - loss o f foreign-educated nurses - another method was presented that described the range o f estimates using 3 censuses. We created a synthetic cohort o f nurse immigrants for each year o f immigration (e.g. 1970 to 1974, 1975 to 1979.. .), and compared them between 3 censuses. Theoretically, if all nurses that were present in 2000 were educated outside o f US, the number o f nurses in each immigration cohort should be decreasing over time due to death and out-migration. Therefore, any observation o f an increase would represent the number o f foreign-born who were educated in the destination countries. We used the minimum number o f nurses in each cohort over 3 census period to estimate the current 70 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform stock o f foreign-educated nurses. We chose this number because any number higher would have included foreign-born nurses who were educated in the US. I t should be noted that data on whether ES CARICOM trained nurses who are living in the U S are working as a nurse or not i s not available. I t should also be noted that the presented stock estimates may underestimate the true number o f ES CARICOM trained nurses in the prime destination countries. Injlow o ES CARICOMtruined nurses to in selected OECD countries f Canada We estimated the inflow o f ES CARICOM trained registered nurses to Canada for the period 2001 to 2005. Data was provided by the Canadian Institute o f Health and Information at our request, which included a l l nurses who were registered with Registering and Licensing Authorities in each o f the provinces and territories. A limitation o f this source was that it did not include ES CARICOM-trained registered nurses who were not registered with Registered and Licensing Authorities but lived in Canada. UK We estimated the inflow o f ES CARICOM trained registered nurses to the UK for the period o f 2001 to 2005. I t should be noted that the UK begins counting newly registered nurses in the mid-year. Data was obtained from the website o f the Nursing and Midwifery Council (NMC), which included a l l nurses who were registered with the NMC. A limitation o f this source was that it did not include ES CARICOM trained registered nurses who were not registered with the N M C but lived in the UK. us We estimated the inflow o f ES CARICOM trained registered nurses to the U for the S period o f 2004 to 2006. Data was obtained from the website o f the National Council o f State Board o f Nursing (NCSBN), which included all nurses who had passed the Nursing Council Licensure Examination (NCLEX). NCLEX i s a prerequisite for registering with the State Board o f Nursing. Therefore, not all nurses who had passed the NCLEX would have necessarily registered as a R N s in the US. Another limitation o f this source was that it did not include ES CARICOM trained registered nurses who did not take NCLEX exam but lived in the US. 71 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Jamaican Nurse Labor and Education Survey The objective o f the Jamaican Nurse Labor and Education Survey was to identify labor and education market behaviors as well as their determinants. This survey included registered nurses (RNs) who had completed the general nursing program (3 years, diploma only) for the years 1980, 1990, 2000, and 2005 from Excelsior Community College and Kingston School o f Nursing. As discussed in the ES C A R I C O M Case Country Study section, a database, which was created in Phase I o f this project, contained contact information for all R N s who graduated in the abovementioned nursing programs from the four cohorts. Contact information includes name, address, telephone number, and/or email address. This information comes from The Nursing Council o f Jamaica Registry. In order to graduate from a general nursing program and receive licensure to practice, a student must pass the Regional Examination for Nurses Registration (RENR). After passing this exam, but prior to working, all qualified R N s must register with the Nursing Council o f Jamaica. Since Jamaican nurses need only register one time in their professional careers, this source o f contact information i s the most complete. Therefore, it i s from this registry that information for the database was collected. There were several approaches used to contact nurse graduates. The first attempt was to use the contact information collected in the database. If the R N s ' contact information was not up to date, the next attempt was to contact hospitals (matrons and co-workers) to determine current contact information o f these nurses. Another approach to locating R N s was to ask respondents o f the survey if they had contact information o f their classmates. The Jamaican Nurse Labor and Education Survey was a telephone-based survey. The questionnaire used in this survey was developed in response to a l i s t o f research questions aimed at understanding the behavior o f nurses in the labor and education market. W e studied and adopted various existing surveys o f migration and human resource for health. Four sample questionnaires on health care workers and migration served as models in creating this questionnaire. The questionnaire i s composed o f sections relating to individual characteristics, income, education, migration, employment, and j o b satisfaction. Four groups o f respondents were identified: 1) non-migrant non-nurse, 2) non-migrant nurse, 3) migrant non-nurse, and 4) migrant nurse f Limitations o the Jamaica Nurse Labor and Education Survey As we moved further away from the cohort graduation date, it became increasingly difficult to locate the registered nurses. Therefore data collection for the 1980 was limited. In addition, i t was difficult to locate and contact all registered nurses from the Nursing Council o f Jamaica registry. The contact information from the registry was not the most accurate source o f contact. Especially for nurses who were originally from rural areas and who had migrated into the city to study, often time the contact information was for dormitories or apartment rentals in which they do not live anymore. We were not 72 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform able to identify those who are no longer working as a nurse. It was possible to these numbers are small. Regional Nurse Labor Market Outlook We examined the future supply o f and demand for nurses under current policies over the next 15 years. We also examined the future supply o f and demand for nurses and under alternative nurse education policies scenarios over the next 15 years. We calculated supply and demand projections for the ES CARICOM region and for each case study country. Demand Projection Demand was estimated based on demographic changes and projected utilization patterns o f all ES CARICOM countries from 2007 to 2025. Demographic data, specifically population by five-year age group and sex, were obtained from United Nations Population Divisions (2007) for all ES CARICOM countries except for countries with populations less than 100,000 (Antigua and Barbuda, Dominica, Montserrat and St. Kitts and Nevis). Since the population o f these countries made up approximately 5 YOo f the total ES CARICOM population, the final projection o f demand was adjusted upwards by 5 Yo. Canadian nurse service utilization patterns were used a starting point. I t was acknowledged that nurse utilization patterns would be different between countries; however, these patterns would be quite similar between age-groups. Our reference group was the female 5 to 14 age-group (the lowest nurse utilization rate). We calculated different weights for each subgroup (sex and age-group) relative to the reference group (Table B2, Weight 1). Weight 1 represented Canadian nurse utilization patterns. To adjust for the fact that ES CARICOM citizens were likely to die earlier than their Canada counterparts, heavier weights were placed only on the older age groups (45 years and above). Weight 2 and 3 represented different magnitudes o f weights placed on older age groups (Table B2, Figure SI). 8 65-74 421.8 350.9 27.2 22.6 41.4 47.3 67.6 72.0 9 75+ 1048.5 1116.3 67.6 72.0 67.6 72.0 67.6 72.0 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Using weights (w,,) and population size for each subgroup (sex and age-group), relative size o f nursing needs that take into account demographic changes over time were calculated as the following: rNl = (~op,,,~,, )wo3x,t However, the exact number o f nurses required could not be determined. We assumed that the sum o f the current number o f nurses (N) and the current number o f vacancies (V) would correctly reflect current need. Therefore, annual need was calculated as following: This method only incorporated the demand due to demographic change. Concerns were raised that current vacancy rates, as an indicator o f unmet demand, may understate the true needs o f poorer countries in the region. Therefore, the demand was projected from 2015 onward based o n nurse per population that gradually increased to regional maximum o f 2.7 per 1000 by 2025. The same method was used to calculate the demand for each individual case study country. Figure B1: Utilization Weights Male 1 Female 80 i " ? 60 "4 I i I * 4 40 I ? f 20 Agecat 1 weight1 ------e- - -- - *-- weight2 - ___ - _ __ weight3 e ___ i Graphs by sex 74 The Nurse Labor and Education Markets in the English-Speaking CAIUCOM: Issues and Options for Reform Supply Projection Base Case Scenario Future supply o f nurses in the ES C A R I C O M was estimated based on information from the ES C A R I C O M country case study o n current stock, education output, and current attrition rate. Current nurse stock in ES C A R I C O M was approximately 7,800 nurses, annual education output was 585 nurses, and regional attrition rate was 0.079. We assumed both education output and regional attrition rate would not change if current policies were maintained. The following equations represent the calculations for all future annual supply. where t i s year and t=l i s year 2007 S i s supply The same method was used to calculate the supply for each individual case study country. Alternative Policy Scenarios Table B 3 summarizes the two scenarios applied in this report. In these scenarios, we assumed that current stock and attrition rates remained the same. These two scenarios represented possible changes that could be made to increase the nurse workforce. Specifically we targeted improvements in the completion rate and an increase in the intake o f students. Feasibility o f these scenarios was tested based on existing constraints in the nurse education market. Constraints that were considered included number o f nurse tutors, clinical training opportunities, and number o f qualified applicants as discussed in the main report. As shown in the report, both clinical training opportunities and number o f qualified applicants were not binding constraints. Nurse tutors were a critical input to improve completion rates as well as increase the intake o f students. Using information collected in case study countries, we estimated that there were 90 nurse tutors in ES CARICOM. Student/Tutor ratio was calculated with following assumptions: 1) Students stay in the school on average 3.5 years; and 2) students drop out on average in the middle o f the program. Student/Tutor Ratio = (student intake into pre-service training programs + net increments)/2 x 3.5 / /nurse tutor 75 The Nurse Labor and Education Markets in the English-Speaking CARTCOM: Issues and Options for Reform Scenario I As described in the report and Table B3, completion rates would increase from 55 percent to 85 percent by 201 1. This would occur gradually at first given that an increase in nurse tutors would not occur immediately. Therefore, we calculated a 2 year lag before the first increase in nurse tutors produces an improvement o f completion rates and increase in number o f nurse graduates. By 201 1, we assumed completion rates would remain constant at 85 percent thereafter. In this scenario, we would increase the intake o f students by 50 percent. It should be noted that there would be o n average a 3 to 4 year lag before the first increase in intake o f students produces an increase in the number o f nurse graduates. This i s due to the fact that pre-service training programs are o n average 3 to 4 years. Therefore, if these projections begin in 2007, the first indication o f this policy change would result in 2010. This would result in an increase o f nurse graduates from 585 to 1,340 by 2015 and constant thereafter. For the abovementioned policy changes, the number o f nurse tutors would need to be increased f i o m 90 to 5 10. This calculation was based o n intake o f students, number o f graduates, and studenthutor ratio. In our analysis, we aimed at a target o f a student- teacher ratio o f 10: 1. In our calculations, we used the average value o f student intake and number o f graduates to calculate the number o f nurse tutors needed. This value better reflects the number o f students tutors had to teach. Average number o f students per year (midpoint) = intake o f students) + (number o f graduates)/2 Total number o f students in the program = 3.5 (duration o f program) x (Average number o f students per year) Total number o f nurse tutor required = (total number o f students in the program)/(student/tutor ratio) The same method was used to calculate the supply for each individual case study country. Scenario 2 As described in the report and Table B3, completion rates would increase from 55 percent to 85 percent by 201 1. This would occur gradually at f i r s t given that an increase in nurse tutors would not occur immediately. Therefore, we calculate a 2 year lag before the first increase in nurse tutors produces an improvement o f completion rates and increase in number o f nurse graduates. By 201 1, we assumed completion rates would remain constant at 85 percent thereafter. In this scenario, we would increase the intake o f students by 100 percent. I t should be noted that there would be o n average a 3 to 4 year lag before the first increase in intake o f students produces an increase in the number o f nurse graduates. This i s due to the fact 76 The Nurse Labor and Education Markets in the English-Speaking CARICOM. Issues and Optionsfor Reform that pre-service training programs are on average 3 to 4 years. Therefore, if these projections begin in 2007, the first indication o f this policy change would result in 2010. This would result in an increase o f nurse graduates from 585 to 1,800 by 2015 and constant thereafter. For the abovementioned policy changes, the number o f nurse tutors would need to be increased from 90 to 680. This calculation was based on intake o f students, number o f graduates, and student/tutor ratio. In our analysis, we aimed at a target o f a student- teacher ratio o f 10:1. In our calculations, we used the average value o f student intake and number o f graduates to calculate the number o f nurse tutors needed. This value better reflects the number o f students tutors had to teach. Average number o f students per year (midpoint) = intake o f students)+(number o f graduates)/2 Total number o f students in the program = 3.5 (duration o f program) x (Average number o f students per year) Total number o f nurse tutor required = (total number o f students in the program)/(student/tutor ratio) The same method was used to calculate the note for each individual case study country Table B3: Scenarios Estimating nurse wage differentials between ES CARICOM countries and the United States As discussed in the report, U immigration and entry regulations create a quasi- S experiment that allows identifying and analyzing determinants o f migratory flows. A s part o f our analysis o f such determinants, we compared wage differentials between the S U and ES C A R I C O M countries t o migratory flows. We calculated wage differentials as 77 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform hourly nurse wages in selected ES C A R I C O M countries over hourly nurse wages in the us. For the United States, census data allowed calculating nurse wages per hour in 2005 broken down by age groups. However, for ES C A R I C O M countries, census data were scarce and samples too small to calculate wages o f nurses. Instead, we estimated hourly wages for the age group 20 to 29 o n the basis o f information on pay and nurse workforce distribution by cadres in the public sector. This approach seemed justified as more than 90% o f all nurses in the selected countries worked in the public sector. More specifically, we constructed country-specific career paths. For all entry level cadres, we calculated the average salary according to pay with 5 years o f work experience. For all second level cadres, we calculated average salaries based o n 2.5 years o f work experience. We then constructed an average wage based on using a fixed distribution o f 90:lO between entry and second level cadres and a distribution within entry and second level cadres based o n country-specific distributions. For the purpose o f the analysis, we obtained information on annual or monthly net salaries from the five case study countries as well as from Barbados. W e converted net salaries into hourly wages assuming 210 work days per year which allows for holidays, sick-leave and training and using country specific information o n weekly work hours as stipulated in contracts for public employees. Furthermore, we adjusted hourly wages for inflation to arrive at 2005 data that we converted from local currencies into U S Dollar by using the average exchange rate in 2005 and data on purchasing power parity. Costs o f strengthening and expanding nurse training capacity We estimated the costs o f strengthening and expanding nurse training capacity in the ES C A R I C O M based on the two scenarios presented in Table B3. We used a budget approach, that is, we estimated costs for each calendar year. The approach entailed differentiating between recurrent and capital costs, the former further broken down into costs o f quality improvements and the recurrent costs o f expanded training capacity, and developing an investment strategy for each scenario. In addition to those presented earlier, investment strategies built on the following assumptions: First, recurrent costs o f existing programs would have to be increased by approximately US$ 380 per student or 20% o f recurrent expenditures o f schools with high completion rates to achieve quality improvements in the region as a whole. These investments would start immediately. Second, additional nursing schools would have o n average a capacity o f 120 students. Third, capital investment would be made over time span o f 3 years in scenario 1 and over a period o f 4 years in scenario 2. Data o n recurrent and capital costs were taken from St. Vincent and the Grenadines and Jamaica. We used capital costs data from St. Vincent and the Grenadines (Ministry o f health and the Environment, 2003 - 2005) and recurrent costs data from Jamaica (Finance Division Ministry o f Health, 2005). As necessary, data were adjusted for inflation using 78 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform 2005 as the base year; firthermore, information in local currencies were converted into U S Dollars by using the average exchange rate for 2005 adjusted for the purchasing power parity in the same year. Cost Benefit Analysis We developed a decision model to evaluate the current finance mechanism o f the nurse education system in Jamaica. We conducted a cost-benefit analysis o f the training o f one Jamaican nurse to identifl to whom cost and benefits accrue among the key stakeholders: Jamaican nurses, Jamaica, Canada, the UK, and the US. The information obtained in this analysis served to more fairly assign costs to those who benefit. The TreeAge Pro Suite 2008 from TreeAge Software, Inc. was used to run these analyses. We first identified the key stakeholders to be Jamaican nurses, Jamaica (government and employers), Canada (government and employers), the UK (government and employers), and the U S (government and employers). We assigned costs and benefits to each key stakeholder. Based on the current financing scheme o f nurse education in Jamaica, we determined that costs would be assigned to Jamaica (cost o f nurse training) and nurse students (tuition paid). We determined that benefits would be assigned to nurse students (lifetime salary), Jamaica (VAT from spending o f remittances), Canada (savings in nurse training), the UK (savings in nurse training), and the U S (savings in nurse training). Next, we calculated the total costs and benefits for each stakeholder. We defined the duration o f the model to be 39 years, which encompassed the time period starting as a nursing student until retirement. The following describes in detail the calculation o f total costs and benefits for each stakeholder. 1. Calculation o f costs assigned to Jamaica: Cost o f training a nurse in Jamaica. In line with free tertiary education policies, Jamaica highly subsidizes nurse training. The cost o f training a nurse in Jamaica was calculated based o n the average total cost o f training a nurse in the general nursing degree programs (3 years, diploma only) in Jamaica. These results were discounted by 3 percent. All information was based o n finding from the case country studies. These results were converted to international $2005 PPP. 2. Calculation o f costs assigned to nursing students: Tuition for nurse training program. Despite high levels o f public subsidization, there i s a trend towards co-payments b y students. The cost o f tuition a Jamaican nursing student has to pay was calculated based o n the average total tuition paid during the general nursing degree program (3 years, diploma only) in Jamaica. These results were discounted by 3 percent. All information was based o n findings from the country case studies. These results were converted to international $2005 PPP. 79 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform 3. Calculation o f benefits assigned to nurse student: Lifetime salary. The projected lifetime salary earned while working as a nurse was assigned as a benefit to Jamaican nursing students. Given that migration frequently plays a role in the working l i f e o f Jamaican nurses, several different scenarios were studied: non-migrant nurses who work in Jamaica for their whole working life; migrants who leave immediately after completing nurse training and work abroad for their whole working life; and migrants who work in Jamaica for a portion o f their working l i f e and then migrate to work abroad. In this latter case we examined four scenarios: nurses who work in Jamaica for 5 years, 15 years, 25 years, and 30 years respectively before migrating to work abroad. For the calculations o f lifetime salary, we assumed the working l i f e o f a Jamaican nurse to be 35 years. We took into account the different lifetime salaries earned in Jamaica, Canada, UK, and the US, and discounted by 3 percent. Different summations o f lifetime salaries were calculated depending on the length o f time nurses worked in Jamaica or abroad. In order to estimate the average lifetime salary per nurse, we calculated different probabilities: Probability o f migration; probability among migrants o f choosing to work in Canada, the UK, or the US; probability o f working exclusively in Jamaica as a nurse; probability o f working exclusively abroad as a nurse; and probability o f working in Jamaican for a portion o f a nurse's working l i f e and then migrating to work abroad. Data was used from the findings o f the case country study and Jamaica nurse survey, and wage information from the UK National Statistics: Labour Market New Earnings Survey 2003, Census Canada 2001, and Census USA 2000. These results were converted to international $2005 PPP. 4. Calculation o f benefits assigned to Jamaica: Value Added Tax (VAT) from spending o f remittances. V A T collected from items purchased with remittances sent by migrant nurses was assigned as a benefit to Jamaica. Calculations assumed that the entirety o f remittances was spent on taxable purchases in Jamaica. We assumed that on average Jamaican nurses migrate after 10 years o f working in Jamaica; therefore, we calculated the total annual VAT from spending o f remittances over 25 years and discounted by 3 percent. Data was used from the findings o f the case country study and Jamaica nurse survey, and Doing Business 2008: Paying Taxes in Jamaica (2008). These results were converted to international $2005 PPP. 5. Calculation o f benefits assigned to Canada: Savings in training expenses. The savings in training costs that Canada would have had to spend on training a nurse in Canada was assigned as a benefit to Canada. Since all training o f Jamaican nurses occurred in Jamaica, Canada did not use any internal resources to train these nurses. Due to the unavailability o f data on nurse training costs in Canada, information on the cost o f training a nurse in the UK (2007) was used for these calculations (see Benefits assigned to the UK). These results were adjusted to 2007 international purchasing power parity value. Then these results were converted to Canada $2007 and finally deflated to Canada $2005. 80 The Nurse Labor and Education Markets in the Eiiglish-Speaking CARICOM: Issues and Optionsfor Reform 6. Calculation o f benefits assigned to the UK: Savings in training expenses. The savings in training costs that the UK would have had to spend on training a nurse in the UK was assigned as a benefit to the UK. Since all training o f Jamaican nurses occurred in Jamaica, the UK did not use any internal resources to train these nurses. The cost o f training a nurse in the UK was calculated based on the average total cost o f training a nurse in the equivalent Jamaican general nursing degree programs (3 years, diploma only) in the UK. These results were discounted by 3 percent. Information was based o n finding from the UK Council o f Deans (2008). Finally, these results were adjusted to purchasing power parity values o f UK (2005) and deflated to UK pounds (2 005). 7. Calculation o f benefits assigned to the US: Savings in training expenses. The savings in training costs that the U S would have had to spend on training a nurse in the U S was assigned as a benefit to the US. Since all training o f Jamaican nurses occurred in Jamaica, the U S did not use any internal resources to train these nurses. Due to the unavailability o f data on nurse training costs in the US, information o n the cost o f training a nurse in the UK was used for these calculations (see Benefits assigned to the UK). These results were deflated to UK pounds (2005) and then converted to U S dollars (2005). A decision model based on the abovementioned costs, benefits, and probabilities for each key stakeholder (Jamaican nurse, Jamaica, Canada, the UK, and the US) was created. The decision model began with a nurse's choice to migrate. For those nurses who did not migrate, the sole node in the decision tree was a nurse's choice to work as a nurse, which served as a terminal node. For those nurses who migrated, the subsequent decision tree pathway was more detailed. The first node in the decision tree pathway was a nurse's choice in destination country (Canada, the UK, or the US). The second node was a nurse's choice to work as a nurse. The terminal node consisted o f various sets o f combinations o f years working as a nurse in Jamaica and abroad (working in Jamaica for 5 years, 15 years, 25 years, and 30 years respectively before migrating and working abroad). For this model, we assumed the working l i f e o f a Jamaican nurse to be 35 years. To determine who bore the costs and benefits o f training one Jamaican nurse, we calculated the expected costs and benefits for each key stakeholder and for each subsequent terminal node. Based on the probability for each distinct decision tree pathway, we calculated the average o f each result o f expected costs and benefits for each key stakeholder. Therefore, under current financing policies and migration patterns, we were able to estimate the expected costs and benefits for each key stakeholder in the process o f training one nurse in Jamaica. 81 The Nurse Labor and Education Markets in the English-Speaking CARICOM. Issues and Optionsfor Reform AIO ANNEXC: E S C RC M CASECOUNTRY STUDIES In close collaboration with the participating governments o f five ES C A R I C O M countries, Guyana, Jamaica, St. Lucia, St. Vincent and the Grenadines, and Trinidad and Tobago, we studied their nurse labor and education markets. Collectively, these countries represent approximately 80 percent o f total ES C A R I C O M population. Findings reflect information collected and triangulated from multiple sources including the Ministries o f Health (MOH), Ministries o f Education (MOE), nursing schools and councils, and public and private health care facilities. Data was further validated through key informant interviews and information published in the literature. Gathered data provided a comprehensive picture o f the regional nurse labor market including active supply, vacancy rates, attrition rates, wages and immigration. In addition, this information shed light o n key features o f the education market including characteristics o f the supply o f education (number o f schools, intake, completion rates) and i t s cost and financing. Some o f the tables in this Annex reference other tables in "Annex A: Statistical Annex (namely A9, A10, A l l , A12, A13, A14, A15 and A16). Definitions o f terms used in the annex Active Supply/Nurses The number o f nurses employed The number o f nursing positions in public sector Established Posts established bv the government The number o f established nursing positions that are Funded Posts funded by the government The number o f approved and funded positions that are Vacancies unfilled The number o f nursing personnel leaving the workforce Attrition due to various reasons within a specified period o f time Guyana Overview The Cooperative Republic o f Guyana i s an independent nation with a population size o f 740,000. It i s located on the northeast coast o f South America. Guyana has a GDP per capita in PPP o f approximately $3,300, and a ranking o f 97 out o f 177 in the 2007-2008 U N D P Human Development Index. Guyana spends 5.4 percent o f its total GDP and 8.3 percent o f i t s total government expenditure on health, making Guyana's health care system largely publicly financed. The government provides funds for nearly 84 percent o f health care expenditures ( W H O 2005). The rest o f the total expenditure on health is made up by private funds, o f which 100 percent is out-of-pocket. 82 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Options for Reform Source: Guyana (2005) from World Health Statistics (2008) *Public, Private and External do not add to 100%. External resources are considered as part o f public health expenditure Health Care System The health care system in Guyana i s decentralized with the public sector playing a very large role in health care delivery. Health programs are planned and implemented by the M O H in collaboration with the Regional Democratic Council. Guyana's health care delivery system i s composed o f five distinct levels. Level 1 consists o f health posts and stations providing health promotion and preventive care in remote areas. At level 2, health centers provide preventive, curative, and rehabilitative services. Level 3 consists o f district hospitals that have on average 20 to 25 beds and provide diagnostic, inpatient, and outpatient services. At level 4, regional hospitals provide general inpatient and outpatient services in medicine, surgery, obstetrics and gynecology, orthopedics and pediatrics. At level 5, the National Referral Hospital provides diagnostic, specialist, inpatient, and outpatient services. The private sector plays a small role in health care delivery. There are six private hospitals in Guyana and all are located in the capital city, Georgetown. These hospitals have a maximum o f 35 hospital beds. In addition to public and private hospitals, there are various agencies (e.g. National Insurance Scheme), NGOs (e.g. the Parental Association), and foundations (e.g. The Foundation for Oncology) that provide health care services in Guyana. Nursing Professions The categories o f nursing personnel are divided into five disciplines: (i) care at the secondary and tertiary level, (ii) care at the primary level which includes community i i supervision, administrative and management, (iv) education (tutors), and health care, ( i ) (v) others. Active supply (Table A12) In 2007, the total number o f active nurses in Guyana was 405. This represents 0.40 nurses per 1,000 populations involved in the direct provision o f care (disciplines i and ii above) and 0.55 total nurses per 1,000 populations. Nurses working in the secondary and tertiary level compose 68 percent o f the active supply o f nurses. Supervision, administration, and management positions compose 22 percent o f the active supply o f nurses. 10 percent o f nurses work in primary care with an additional 10 percent o f the active supply o f nurses in education. 83 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Vacancies (Table A I 3) In 2007, the total number o f vacancies in the nurse labor market in Guyana was 470. This represents a 54 percent vacancy in the nurse labor market. There are 220 vacant general nurse positions and 145 vacant specialized nurse positions at the secondary and tertiary level and 60 vacant positions in supervision, administration, and management. These three areas account for 90 percent o f the total vacancy in the nurse labor market. In addition, there are 25 vacant positions in primary care level and 20 vacant positions in nurse education. Nursing Attrition (Table A14) In Guyana, the rate o f attrition from the nurse labor market was 18.5 percent in 2007. According to the data, 75 nurses were reported to have left the nurse labor market for various reasons: 7 retired, 1 died, 55 migrated, and the remaining 12 nurses did not specify reasons for leaving. I t must be noted that this data may be an underestimation of the actual attrition rate given that all hospitals could not provide data on annual attrition and formal exit interviews were not conducted with all nurses. Additionally, the nurse registry in Guyana does not have up to date information on nurse attrition. Immigration There were nine nurses who immigrated to Guyana during the period 2002 to 2007. All foreign nurses were registered nurses and all came from India. Nursing Education Guyana has five nursing schools (see Table C2): Georgetown School o f Nursing, N e w Amsterdam School o f Nursing, Charles Roza School o f Nursing, St. Joseph's Mercy Hospital School o f Nursing, and University o f Guyana. These schools offer both pre- service courses (diploma in three-year general nursing program) and in-service courses ('yost-basic programs that include one-year midwifery program and bachelor's degrees). With the exception o f University o f Guyana, all nursing schools are under the direct control o f the MOH. Except for St. Joseph's Mercy Hospital School o f Nursing, all nursing schools are public. Public nursing schools are tuition-free and offer stipends to students. ' Our vacancy information i s based o n information f r o m a report o n the number o f nurses approved for each position subtracted from the number o f filled positions at regional health centers. Currently the method t o measure vacancy i s to subtract the appointed from the established. There has been n o recent study o f existing positions and the need for additional positions; therefore, the data used may not truly represent the needs for the nurse workforce. At the central government level, a needs assessment was performed t o measure the actual employment needs. At the regional level, the Ministry o f Regional Health recommends the number o f approved spots for the regional health care centers. The regional health care centers submit the estimated number o f necessary nurses t o the Public Service Ministry who makes the final decision. 84 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Diploma in General Georgetown Pre 36 Public Y Y Y Nursing Diploma in Georgetown In 12 Public Y Y Y Midwifery New Diploma in General Pre 36 Public Y Y Y Amsterdam Nursing New Diploma in In 12 Public Y Y Y Amsterdam Midwifery Charles Roza in Diploma in General 36 Public Y Y Y Linda Nursing Charles Roza in Diploma in In 12 Public Y Y Y Linda Midwifery St. Joseph's Pre Diploma in General 36 Private Y Y Y Mercy Hospital Nursing Bsc Nursing / Public Health: University o f Autonomous In Health Service Guyana 12/24 Public Manager / Health Science Tutor Y: Yes Requirementsfor Nurse Registration Registered nurses receive their diploma after passing their final exams from a three-year recognized nursing program. Nursing students have up to three opportunities to pass their final exams. After graduation, nursing students can apply for their license to practice as a registered nurse. In addition, all qualified Registered Nurses and Midwives must be registered with the Nursing Council in order to practice their profession. In Guyana, nursing students are not required to participate in the Regional Nursing Council Registration Examination (RNCRE) in order to receive licensure to practice. I t should be noted that the nurses from the other four countries in thes case studies are required to participate in the RNCRE. Cost of Nurse Education and Financingfor Education The government o f Guyana supports the training o f nursing students by offering stipends. Students in the Professional Nurse Education program at any o f the three public nursing schools receive a stipend o f $ GYD 15,00O/month. Private nursing schools also provide stipends to their students. In addition, these schools require the fulfillment o f a two-year 85 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform post-education work contract at affiliated hospitals. It should be noted that the Bachelor's degree in nursing program at the University o f Guyana i s entirely student financed. Student loans may only be accessed through the Ministry o f Finance as there are no provisions for student loans at private banks. Intake o Nurse Training Program f A total o f 246 nursing students entered into a pre-service degree program in nursing schools during the period 2004 to 2006. Output o Nurse Training Program (Table A1 0 and A1.5) f A total o f 115 graduated from nursing schools during the period 2004 to 2006. A total o f 33 graduated from nursing schools in 2006. Those who graduated from other than registered nursing programs during this period are not included in Table A10. The number o f graduates per entrant in the nurse education market for the years 2004- 2006 in Guyana was 0.47. Salaries and Compensation Table C3 shows a summary o f monthly wages by nurse cadre in the public sector. Allowances are not included in the monthly wages. The salary o f many cadres including staff nurse, midwife, ward sister, department sister, health visitor and tutor range between $US 200 to $US 550 per month. The difference between the minimum and maximum salary i s less than $US 100 per month for many cadres, indicating these salaries do not necessarily increase over the years for the same cadre. Source: Ministry o f Health Finance Division , Georgetown Public Hospital Corporation 2007 Amounts are rounded to the nearest ten. This i s the monthly wages in U dollars. USD I= S GYD 202 86 The Nurse Labor and Education Markets in the English-SpeakingCARICOM. Issues and OptLonsfor Reform Government's strategies and policies on human resources,for health, specijkally nurses Guyana's approach to managed human resources o f health workers are mainly (ij to increase the intake o f nursing students, (ii) provide financial incentives, (iiij to to improve the quality o f staff, and (iv) to improve the physical and technical infrastructure o f hospitals. (i) Increase the intake o nursing students f Since 2005, the target number for recruiting nursing students has been 250. This target is three times larger than for the previous years. Although it i s aimed at providing a sufficient number o f nurses for both local employment and possible migration, i t has not been implemented due to the fact that there were not enough students who meet the minimum requirements for entry into the schools. (ii) Provide Jinancial incentives The loss o f teachers through migration has also limited the ability o f schools to increase intake o f nursing students. Increases in monthly allowances were introduced to help cushion the effects o f the high cost o f living and provide a more realistic living wage. (iii) Improve the quality o staff f The introduction o f performance management i s planned. Training opportunities and promotions will be linked to performance which can provide continuous professional development for all staff. (iv) Improve the physical and technical infrastructure Improve facilities to provide better care. New hospitals will be built and new technologies introduced. Jamaica Overview The Commonwealth o f Jamaica i s a constitutional parliamentary democracy with a population o f 2.7 million. It i s located in the northern Caribbean. The GDP per capita in PPP i s approximately $7,200 and Jamaica ranks 101 out o f 177 in the 2007-2008 UNDP Human Development Index. Jamaica spends 4.7 percent o f i t s total GDP and 3.5 percent o f the total government expenditure on health. The country's health care system i s both publicly and privately financed. The government provides funds for almost 49 percent o f health care expenditures (WHO 2008). The rest o f the total expenditure on health i s covered by private funds o f which 64 percent i s paid out-of-pocket. 87 The Nurse Labor and Education Markets in the English-Speaking CARICOM, Issues and Optionsfor Reform Table C4: Summarv o f Jamaica H e a l t h Exsenditure (2005) Source: Jamaica, 2005.froni World Health Statistics (2008). *Public, Private and External do not add to 100%. External resources are considered as part o f public health expenditure Health Care System The health care system in Jamaica i s decentralized. The four semi-autonomous regional bodies, the Regional Health Authorities (South-East, North-East, Western, and Southern regions), provide health care for their populations. Jamaica's health care delivery system i s composed o f these four regions. Nursing Professions The categories o f nursing personnel are divided into five disciplines: (i) care at the secondary and tertiary level, (ii)care at the primary level which includes community health care, (iii) supervision, administrative and management, (iv) education (tutors), and (v) others. Active supply (Table A I 2) In 2007, the total number o f active nurses in Jamaica was 2,835. This represents 0.80 nurses per 1,000 populations involved in the direct provision o f care and 1.06 nurses per 1,000 populations. Nurses working in the secondary and tertiary level compose 67 percent o f the active supply o f nurses. Supervision, administration, and management positions compose 14 percent o f nurses. Nurses working in the primary level compose 8 percent o f the active supply o f nurses. 3 percent o f the active supply o f nurses i s in education and 8 percent o f nurses serves in other health-related areas. Vacancies (Table A I 3) In 2007, the total number o f vacancies in the nurse labor market in Jamaica i s 970 which represents 25.5 percent o f the nurse labor market. Our data shows that there are a total o f 875 vacant general and specialized nurse positions at the secondary and tertiary level and supervision levels. This accounts for 90 percent o f the total vacancy in the nurse labor market. In addition, there are 90 vacant positions in primary care level and 5 vacant positions in nurse education. 88 The Nurse Labor and Education Markets in the English-Speaking CARlCOM: Issues and Optionsfor Reform Nursing Attrition (Table A1 4) In Jamaica, the rate o f attrition from the nurse labor market was 6.5 percent. According to the data, 166 out o f 183 nurses who left the nurse labor market did not specify reasons for leaving and 17 nurses were reported to have left the nurse labor market for various reasons: 14 retired, and 3 died. Immigration There were 91 nurses who immigrated to Jamaica in the period 1999 to 2007. The majority o f the foreign nurses was registered nurses and came from Nigeria and Cuba. It should be noted that the turnover rate among these nurses was very high. Foreign nurses serve a two-year contract in Jamaica and often opt to return to their own country or S migrate to the U or Canada after their contract expires. Nurses in Jamaica in 1999-2006 Cuba 32 BSc. Plus specialization BSc, Psyc, Periop, Nigeria 47 NA Ortho, Paeds, RM, Tutors BSc, MSc, CCU, India 7 Neonata1,Tutors RN, diploma, BSc, RM, Ghana 3 PH Other* 2 Total 91 Nursing Education There are eight nursing schools in Jamaica: the University o f Technology, the University o f the West Indies School o f Nursing (UWISON), Kingston School o f Nursing, Brown's Town Community College (BTCC), Excelsior Community College (EXED), b o x Community College (KCC), Northern Caribbean University, and Cornwell School o f Nursing. These schools offer pre-service and in-service general nursing programs as well as in-service post-basic programs (post general nursing programs such as specialist programs and Master's degree programs). I t should be noted that since 2004, the minimum qualification for all nurse tutors i s a Master's degree. Most o f the nursing schools are under the direct control o f the M O H with the exception o f UWISON, which is an autonomous public school, and Northern Caribbean University, which i s a private school. 89 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Y: Yes Tuition: Requires tuition payment by students Subsidy: Subsidy i s provided to nursing schools StipendiScholarship: Stipend and/or scholarship are available for students Loan. Loan i s available for students Requirements for Nurse Registration In Jamaica, successful nursing students must participate in the R N C R E in order t o receive licensure to practice. The examinations are prepared annually and administered in April and October o f each year. In addition, all qualified Registered Nurses and Midwives must be registered with the Nursing Council o f Jamaica in order to practice their profession. 90 The Nurse Labor and Education Markets in the English-Speaking C4RICOM Issues and Options for Reform Cost o Nurse Education and Financing for Education f The government o f Jamaica supports the training o f nursing students by offering stipends and subsidies to nursing schools. For example, stipends for accommodation are given to students for their first two years o f schooling, and then students are required to pay for their accommodations during their last year. Not all nursing schools and students receive subsidies and stipends. For those who receive scholarships, funding i s obtained mainly from the National Health Fund and Pan American Health Organization. It should be noted that students who receive scholarships for $JA 500,000 are bonded for five-years to work in Jamaica and require three guarantors to secure the funds. This funding i s available for all nurses enrolled in a three- year certificate program at KSN and CSN. The cost per student for the three-year certificate program i s on average $JA 520,000 ($US 7,536). Nurses who have graduated from three-year certificate program are then sponsored for specialist programs such as administration and education. The annual training costs for these post-graduate courses range from $JA 483,000 ($US 7,000) for nursing education, $JA 47,000 ($US 681) for the clinical instructors, $JA 310,000 ($US 4,500) for family nurse practitioners and nursing administration, and $JA 168,000 ($US 2,435) for public health nursing. The annual cost for the Bachelor's degree program varies from $JA 150,000 at KCC to $JA 328,000 at UWISON. Intake o Nurse Training Program f A total o f 101 students entered into nursing schools in Jamaica during the period 2004 to 2006. Output o Nurse Training Program f A total o f 69 graduated from nursing schools during the period 2004 to 2006. Those who graduated from other than the registered nursing program during the period are not included in Table A 10. The number o f graduates per entrant in the education market for the years 2004-2006 in Jamaica i s 0.68. Salaries and Compensation Table C7 shows a summary o f annual salaries by nurse cadre in public sector. Allowances are not included in the annual salary. For most nursing personnel, the average salary i s $US 10,000 per year. 91 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Source: Salary scales Min o f Health Personnel Division , 2007 RN- Registered Nurse, PHN- Public Health Nurse, PNP-Psychiatric Nurse Practitioner, FNP-Psychiatric Nurse Practitioner, NA-Nurse Anesthetists JA/US$69:1 Amounts are rounded to the nearest ten. Government's strategies and policies on human resources for health, specijkally nurses Jamaica's approaches to manage nurse shortages are mainly (i) increase salary levels, to (ii) increase training capacities, (iii) recruit foreign nurses for clinical areas and to to nursing schools, (iv) t o promote Bachelor's degree programs, and (v) to promote additional training for nurses. (i) Increase salary levels There was a pay-freeze until 2005. Salary levels increased only after the lifting o f the pay-freeze. (ii) Increase training capacities Since 1988, there has been a doubling o f the number o f nursing schools from 4 to 8. There has been more clinical placements in training sites. (iii) Recruitforeign nurses for clinical areas and nursing schools To compensate for these shortages and to to increase the number o f nurses in clinical areas and at school, the government has promoted bilateral government agreements, such as the Jamaica and Cuba Technical program and the Jamaica and Nigeria Technical AID Corporation program. (iv) Promote Bachelor's degree programs All general nursing programs (three year diploma program) have been upgraded to the Bachelor's degree program. Upgrading to the Bachelor's degree would promote nursing as a comparative profession for attracting qualified high school graduates. In addition, funding i s available for post-basic bachelor's degree training programs. (v) Promote additional trainingfor nurses Registered Nurses have more opportunities to receive training in additional specialized fields o f nursing such as Ophthalmology, Renal and Oncology. Tutors are encouraged to 92 The Nurse Labor and Education h4arkets in the English-Speaking CARICOM. Issues and Options for Reform obtain a Master's degree to enhance their teaching capabilities and enable professional advancement. St. Lucia Overview Saint Lucia i s a member o f the Commonwealth o f Nations with a population o f 165,000. It i s located in the eastern Caribbean Sea. The GDP per capita in PPP i s approximately $9,335 and St. Lucia ranks 72 in the 2007-2008 U N D P Human Development Index. St. Lucia spends 5.9 percent o f i t s total GDP and 10.3 percent o f the total government expenditure o n health. St. Lucia's health care system i s publicly and privately financed. The government provides funds for 56 percent o f health care expenditures (WHO 2008). The rest o f the total expenditure on health i s covered by private funds o f which 94.3 percent i s paid out-of-pocket. Health expenditure, public (% o f government expenditure) 10.3 Health expenditure, public (% o f total health expenditure) 56.2 Health expenditure, private (YOo f total health expenditure) 43.8 External resources, total (YO f total health expenditure)* o 0.3 Out-of-pocket expenditure (YO f private expenditure o n health) o 94.3 Source: St. Lucia, 2005 from World Health Statistics (2008). *Public, Private and External do not add to 100%. External resources are considered as part o f public health expenditure Health Care System The health care system in St. Lucia i s centralized. The M O H provides primary and secondary services. Nursing Professions The categories o f nursing personnel are divided into five disciplines: (i) care at the secondary and tertiary level, (ii)care at the primary level which includes community health care, (iii) supervision, administrative and management, (iv) education (tutors), and (v) others. Active supply (Table A1 2) In 2007, the total number o f active nurses in St. Lucia was 365. This represents 1.81 nurses per 1,000 populations involved in the direct provision o f care and 2.10 nurses per 1,000 populations. Nurses working in the secondary and tertiary level compose 67 percent o f the active supply o f nurses. Supervision, administration, and management positions compose 16 percent o f active supply o f nurses. Nurses working in the primary 93 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform level compose 15 percent o f the active supply o f nurses and 2 percent o f the active supply o f nurses are in education. Vacancies (Table A I 3) In 2007, the total number o f vacancies in the nurse labor market in St. Lucia was 35, which represents 9 percent o f the nurse labor market. At the time the research was conducted, there were 25 vacant general and specialized nurse positions at the secondary and tertiary level and supervision levels. This accounts for 71 percent o f the total vacancy in the nurse labor market. In addition, there were 15 vacant positions in supervision, administration, and management. These four areas account for the total vacancy in the health care system in St. Lucia. Nursing Attrition (Table A I 4) In St. Lucia, the rate o f attrition from the nurse labor market during the period examined was 7.7 percent. According to the data, 28 nurses left the nurse labor market for various reasons: 10 retired, 4 migrated, and the remaining 14 nurses did not specify reasons for leaving. Immigration There were 48 nurses who immigrated to St. Lucia during the period 2002 to 2007. H a l f o f these foreign nurses were registered nurses and all came from Cuba. Count r? Certificate/Diploma Otlirrs Total plus Specialization - Cuba 24 24 48 Nursing Education St. Lucia has one nursing school, Sir Arthur Lewis Community College. T h i s nursing school offers in-service general nursing programs (3 6 months) and in-service midwifery programs (18 months). Sir Arthur Lewis Community College i s an autonomous public school. 94 The Nurse Labor and Education Markets in the Englwh-Speaking CARICOM: Issues und Options for Reform Y: Yes Tuition: Requires tuition payment by students Subsidy: Subsidy i s provided to nursing schools StipendiScholarship: Stipend and/or scholarship are available for students Loan: Loan i s available for students Requirementsfor Nurse Registration In St. Lucia, successful nursing students must participate in the RNCRE in order to receive licensure to practice. The examinations are prepared annually and administered in April and October o f each year. In addition, all qualified Registered Nurses and Midwives must be registered with the Nursing Council o f St. Lucia in order to practice their profession. f Cost o Nurse Education and Financing for Education The government o f St. Lucia supports the training o f student nurses by offering a subvention to the College. At present, nursing students are required to subsidize their training by paying an annual tuition fee. Intake o Nurse Training Program f A total o f 74 students entered nursing school in St. Lucia during the period 2004 to 2006. f Output o Nurse Training Program A total o f 65 graduated from nursing schools during the period 2004 to 2006. Those who graduated from other than the registered nursing program during the period are not included in Table A 10. The number o f graduates per entrant in the education market for the years 2004-2006 in St. Lucia i s 0.88. 95 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Salaries and Compensation Table C11 shows a summary o f annual salaries by cadre in public sector. Allowances are not included in the annual salary. The average salary o f nurses working in the clinical setting (staff nurse) i s $US 15,000 per year. Source: Ministry o f Health and Labor Relations (Clinical Staft); Lansiquot 2007 (Educators) Not included in salary levels and post has not been filled for a number o f years This i s the annual wages in EC dollars. USD 1= XCD 2.65 Amounts are rounded to the nearest ten. Government's strategies and policies on human resourcesfor health, specijkally nurses St. Lucia's approaches to manage nurse shortages are mainly (i) expand training to programs and (ii) recruit foreign nurses. to f (i) Expansion o training programs Students receive subsidies such as free tuition, registration costs, and books. Registered nurses who continue studies in the midwifery program can do so through a work-study program. This enables these students to continue to work and receive their salaries while they continue their studies. Students are bonded to work for a certain period after graduation. f (ii) Recruitment o foreign nurses In 2006, 24 foreign nurses from Cuba were recruited to St. Lucia to work in the clinical setting at both the primary and secondary level. These nurses served a two-year contract and returned to Cuba upon finishing. St. Vincent and the Grenadines Overview St. Vincent and the Grenadines is a member o f the Commonwealth o f Nations with a population o f 119,000. I t i s located next to Saint Lucia in the eastern Caribbean Sea. The GDP per capita in PPP i s approximately $ 6,798 and i t ranks 92 in the 2007-2008 U N D P Human Development Index. St. Vincent and the Grenadines spends 6 percent o f i t s total GDP and 9.3 percent o f i t s total government expenditure on health. The country's health care system i s both publicly and privately financed. The government provides funds for 63 percent o f health care expenditures (WHO 2008). The rest o f the 96 The Nurse Labor and Education Markets in the English-Speaking CARICOM. Issues and Optionsfor Reform total expenditure o n health is covered by private funds o f which 100 percent i s paid out- of-pocket. Health expenditure, public (?Ao f total health expenditure) 1 62.9 Health exuenditure. urivate (% o f total health exDenditure) 1 37.1 External resources, total (YOo f total health expenditure)* 0.2 Out-of-pocket expenditure ("A o f private expenditure o n health) 100.0 Health Care System The health care system in St. Vincent and the Grenadines i s centralized. The M O H provides primary, secondary and tertiary services. There are three levels o f health care services. At the primary care level, district health centers provide services such as emergency care, medical care, prenatal and postnatal care, midwifery and child health services. At the secondary care level, government owned hospitals and acute care referral hospitals provide specialized health care. It should be noted that the private sector plays a small role in health care delivery in St. Vincent and the Grenadines. Nursing Profess ions The categories o f nursing personnel are divided into five disciplines: (i) care at the secondary and tertiary level, (ii)care at the primary level which includes community health care, (iii) supervision, administrative and management, (iv) education (tutors), and (v) others. Active supply (Table A1 1) In 2007, the total number o f active nurses in St. Vincent and the Grenadines was 305. This represents 1.60 nurses per 1,000 populations involved in the direct provision o f care and 1.79 nurses per 1,000 populations. Nurses working in the secondary and tertiary level compose 80 percent o f the active supply o f nurses. Nurses working in supervision, administration, and management compose 9 percent o f the active supply o f nurses. Nurses working in the primary level compose 9 percent o f the active supply o f nurses and 2 percent o f the active supply o f nurses are in education. Vacancies (Table A1 3) In 2007, the total number o f vacancies in the nurse labor market in St. Vincent and the Grenadines i s 50, which represents 14.1 percent o f the nurse labor market. Vacancies in the secondary, tertiary, and supervision account for 70 percent o f the total vacancy in the nurse labor market. In addition, there are 10 vacant positions in primary care and 5 vacant positions in nurse education. 97 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Nursing Attrition (Table A I 4) In St. Vincent and the Grenadines, the rate o f attrition from the nurse labor market is 6.5 percent. According to the data, 21 nurses left the nurse labor market for various reasons: 6 retired, 1 died, and the remaining 14 nurses did not specify reasons for leaving. Immigration There were 40 nurses who immigrated to St. Vincent and the Grenadines during the period 2002 to 2007. All foreign nurses were registered nurses and more than half came from Cuba. Table C13: Number o f Foreign Nurses Entering St. Vincent and the Grenadines between 2002-2007 Guyana 2 2 Total 18 13 1 8 40 Source: General Nursing Council Register (2002-2007) * Includes BA and Baccalaureate Nursing Education St. Vincent and Grenadines has one nursing school, St. Vincent and the Grenadines School o f Nursing. This school offers a pre-service general nursing program (36 months) and an in-service post basic midwifery program (12 months). This school i s an autonomous public school that i s part o f the St. Vincent and the Grenadines Community College. 98 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reforin School of Nursing Pre Certificate in GN 36 Autonomous Y Y Y Public School o f Nursing Pre Certificate 12 Autonomous Y- Y Y Midwifery Public Requirementsfor Nurse Registration In St. Vincent and the Grenadines, successful nursing students must participate in the RNCRE in order to receive licensure to practice. The examinations are prepared annually and administered in April and October o f each year. In addition, all qualified Registered Nurses and Midwives must be registered with the Nursing Council o f St. Vincent and the Grenadines in order to practice their profession. Cost o Nurse Education and Financingfor Education f The government o f St. Vincent and the Grenadines supports the training o f nursing students by offering stipends to students and subsidies to the nursing school. Intake of Nurse Training Program (Table A1 0) A total o f 200 students entered into a pre-service degree program at the nursing school from 2004 to 2006. Output o Nurse Training Program (Table A1 0) f A total o f 89 students graduated from the St. Vincent and the Grenadines School o f Nursing during the period 2004 to 2006. The rate o f graduate per entrant in the nurse education market for the years 2004 to 2006 in St. Vincent and the Grenadines i s 45 percent. Salaries and Compensation Table C15 shows a summary o f annual salaries by cadre in public sector. Allowances are not included in the annual salary. The salary o f many cadres including staff nurse, 99 The Nurse Labor and Educatioiz Markets in the English-Speaking CARICOIZI: Issues and Options for Reform midwife, ward sister, home sister, clinical instructors range between $US 7,700 to $US 13,500 per year. Specialized nurses such as nurse anesthetists and nurse practitioner receive a salary between US$12,000 and US$16,000 per year. Table C15: Summary o f Wages for Nurse Personnel in St. Vincent and the Grenadines Source: Government Estimates, AdministrativeRecords 2007 S This IS the annual wages in U dollars. USD 1 = XCD2.665 Amounts are roundedto the nearest hundred Government's strategies and policies on human resources o health workers, specijkally f nurses St. Vincent and the Grenadines' approach to managed nurses are mainly (i) reform to nurse education policies and (ii) increase the nursing workforce. to (i) Education Reform In 2003, the government embarked on an ambitious project to strengthen the registered nursing program. The St. Vincent and the Grenadines School o f Nursing was transferred from the Ministry o f Health and the Environment to the Ministry o f Education - Community College (as o f January 2009).-The nursing assistant program will be assessed and modified to allow for matriculation into the registered nurse program once the necessary prerequisites are obtained. The registered nursing program will be upgraded from a three-year to a four-year program. For those who are currently registered nurses, individuals will be upgraded from certificate to first-degree level. The midwifery program will be expanded from a 12-month to an 18-month program and awards diploma upon completion o f the program. Nurses' tutors will be required to have a Master's degree as a minimum qualification. Moreover, the capacity for training registered nurses has increased from 35 to 100 annually in 2003. 100 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform (ii) Increase the nursing workforce To increase the nursing workforce, in 2003, the government implemented policies to increase nurse salaries, increase all allowances including night duty, on call, and traveling, and improve the health centers and nurses quarters. Trinidad and Tobago Overview The Republic o f Trinidad and Tobago i s a country with a population o f 1.3 million. It i s located in the southern Caribbean Sea. The GDP per capita in PPP i s approximately $15,387 and i t ranks 59 in the 2007-2008 U N D P Human Development Index. Trinidad and Tobago spends 4.5 percent o f its total GDP and 8.3 percent o f i t s total government expenditure o n health. Trinidad and Tobago's health care system i s both publicly and privately financed. The government provides funds for 54 percent o f health care expenditures (WHO 2008). The rest o f the total expenditure on health i s covered by private funds o f which 87.8 percent i s paid out-of-pocket. Table C16: Summary o f Trinidad and Tobago Health Expenditure (2005) Indicator Yo Health expenditure, total (YO f GDP) o 4.5 Health expenditure, public (% of government expenditure) 8.3 Health expenditure, public (% o f total health expenditure) 53.7 Health expenditure, private (% of total health expenditure) 46.3 External resources, total (YO f total health expenditure)* o 2.4 Out-of-pocket expenditure (YO private expenditure o n health) of 87.8 Health Care System The health care system in Trinidad and Tobago i s decentralized. The Ministry o f Health develops, monitors, and evaluates health policy and health care delivery. Trinidad and Tobago health care delivery system i s composed o f three distinct levels. Five Regional Health Authorities (RHAs) provide primary, secondary and tertiary services. The five W A S are responsible for the administration o f community health services within nine country health districts. Community health centers provide primary and public health care services. Hospitals and district health facilities provide primary, secondary and tertiary care services. Nursing Professions The categories o f nursing personnel are divided into five disciplines: (i) care at the secondary and tertiary level, (ii)care at the primary level which includes community health care, (iii) supervision, administrative and management, (iv) education (tutors), and (v) others. 101 The Nurse Labor and Education Markets in the English-Speaking CARKOM: Issues and Optionsfor Reform Active supply (Table A I 2) In 2007, the total number o f active nurses in Trinidad and Tobago was 2,380. This represents 1.60 nurses per 1,000 populations involved in the direct provision o f care and 1.79 nurses per 1,000 populations. Nurses working in the secondary and tertiary level compose 61 percent o f the active supply o f nurses; nurses working in supervision, administration, and management compose 19 percent o f the active supply o f nurses; 15 percent o f the active supply o f nurses are working at the primary level; and 5 percent o f the active supply o f nurses are in education. Vacancies (Table A I 3) In 2007, the total number o f vacancies in the nurse labor market in Trinidad and Tobago was 1,240 which represents 34.3 percent o f the nurse labor market. There are 765 vacant general nurse positions and 75 vacant specialized nurse positions at the secondary and tertiary level. The subtotal o f these three areas makes up 68 percent o f the total vacancy in the nurse labor market. There are 250 vacant positions in supervision, administration, and management. These four areas account for 88 percent o f the total vacancy in the nurse labor market. In addition, there are 90 vacant positions in primary care level and 60 vacant positions in education. Nursing Attrition (Table A I 4) Data o n attrition was unavailable from all hospitals in both the private and public sectors. Immigration There were a total o f 216 nurses who immigrated to Trinidad and Tobago during the period 2002 to 2007. All foreign nurses came from either Cuba or the Philippines. Number of Nurses Philippines 124 Total 216 Source: Records from Nursing Division, Ministry o f Health 2007. Nursing Education Trinidad and Tobago has several nursing schools. These are associated with either the MOH, College o f Science, Technology, Applied Arts o f Trinidad and Tobago (COSTAATT), the University o f West Indies at St. Augustine, and the University o f Southern Caribbean. These schools offer programs such as general nursing programs (36 and 48 months) and post-basic programs such as midwifery and other specialized programs (6 to 24 months). With the exception o f the University o f West Indies and 102 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Options for Reform University o f Southern Caribbean, nursing schools are under the direct control o f the MOH or COSTAATT. Y Nursing M o H SPBNE In Certificate Neonatal 9 Public Y Nursing M o H SPBNE In Certificate Renal 6 Public Y 1 Nursing MoHSPBNE 1 In I Certificate Community I 6 1 Public Y Science in Psychiatric Y ~ Y Y Y Y: Yes, (Y): some students are required to pay tuition Tuition: Requires tuition payment by students Subsidy: Subsidy i s provided to nursing schools StipendiScholarship: Stipend and/or scholarship are available for students Loan: Loan i s available for students Requirementsfor Nurse Registration In Trinidad and Tobago, successful nursing students must participate in the RNCRE in order to receive licensure to practice. The examinations are prepared annually and administered in April and October o f each year. In addition, all qualified registered 103 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform nurses and midwives must be registered with the Nursing Council o f Trinidad and Tobago in order to practice their profession. All other registration examinations such as for psychiatric nursing and midwifery are conducted locally. Cost o Nurse Education and Financing for Education f The government o f Trinidad and Tobago supports the training o f nursing students by offering stipends. Intake o Nurse Training Program f A total o f 457 nursing students entered into a pre-service degree program in nursing schools from 2001 to 2003. Each nursing school has a different schedule for students' intake. Private nursing schools admit students in the fall o f each year. Government schools admit nursing students on a less regular schedule depending o n administrative and budgetary constraints. Each nursing schools only accept applicants from designated districts. Output o Nurse Training Program f A total o f 263 graduated from nursing schools during the period 2004 to 2006. Those who graduated from other than the registered nursing program during the period are not included in the table (Table AlO). The number o f graduates per entrant in the education market for the years 2004-2006 in Trinidad and Tobago i s 0.58. Salaries and Compensation Table C19 shows a summary o f monthly salaries by cadre in the public sector. Allowances are not included in the monthly salary. The salary o f most cadres range between $US 1,000 and $ U S 1,300 per month. The lowest salary among all the cadres i s that o f midwives who earn on average $ U S 860 per month. NursingiClinical Instructor $1,180 $1,350 CountyiDistrict Health Visitor $1,230 $1,370 Nursing SupervisoriAdministrator $1,230 $1,380 104 The Nurse Labor and Education Markets in the English-SpeakingCARICOM: Issues and Optionsfor Reform S This is the monthly wages in U dollars. USD 1= TTD 6.3 183 f Government 's strategies and policies on human resources o health workers, specifically nurses Trinidad and Tobago's approach to managed nurses are mainly (i) reform nurse to education policies, (ii) recruit foreign nurses, (iii) provide financial incentives, and to to (iv) to increase the size o f human resource capacity. (i) Education Reform Education reform policies includes providing continuing education programs for registered nurses, increasing the number o f post registered nurse training programs, establishing a Bachelor's o f Nursing degree program at the U W I in St. Augustine with a focus o n three specialties: education, administration, and nursing. Finally, the reforms seek to increase stipend amount for nursing students and continue to support "free tertiary education" policy. f (ii) Recruitment o foreign nurses In 2003, M O H has adopted a policy to recruit foreign nurses to assist with the potential shortfall in nursing manpower. Since then 92 Cuban nurses and 174 Filipino nurses have immigrated to Trinidad and Tobago and have been deployed in a number o f critical areas including education, intensive care nursing, and community health nursing. All contracts are based on three-year agreements with options for renewal. To increase the nursing workforce, the government has also implemented policies to increase nurse salaries, increase all allowances including night duty, on call, and traveling, and to improve the health centers and nurses quarters. (iii) Provide financial incentives Since 2002, a 25 percent increase in monthly allowances was added to nursing salaries. In addition, nurses are provided with a monthly specialization allowance that i s provided even if they are not assigned to a particular clinical area. (iv) Increase human resource capacity The government has established i p ~ ~ land "seasonal" schedules: "pool" schedules will " allow nurses who want to work extra hours to enter the "pool" for the opportunity to be called o n to work in times o f nursing shortages: and "seasonal" schedules will allow nurses who cannot work the regular five-day shift to work at agreed times and days consistent with institutions needs. 105 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform ANNEXD: OECD CASE COUNTRY STUDIES (This analysis was concluded November 2007. Changes in immigration policy after this date will not be reflected in this document.) This section presents analyses o n 1) the inflow o f ES C A R I C O M nurses to Canada, the UK, and the US, 2) the current stock o f ES C A R I C O M nurses in these countries, 3) the wages earned by ES C A R I C O M nurses in these countries, and 4) the immigration and licensure policies o f these countries. The inflow and stock data are presented in section F o f the main report and an estimation methodology i s provided in the Methodology Annex. Immigration and licensure policy information i s discussed in the background o f this Annex. After discussion immigration issues generally, we will then present 3 case studies for each country. In each case study, we will discuss issues such as the inflow and stock o f ES CARICOM, and immigration requirements for nurses. `Inflow' refers to the number o f migrant nurses who entered to a destination country during a specified time period and `stock' i s the accumulated number o f foreign nurses in a destination country at a given point in time. International labor migration i s a complex, expensive, and time consuming process for both prospective migrants and employers. Migrants are required to obtain the appropriate visas, permits, and other necessary certifications needed to work in destination countries. The licensure and immigration processes are vastly different in each destination country. For example, in both Canada and the US, licensure policies are determined at the provincial/state level, whereas in the UK the licensure process i s determined nationally. With respect to the immigration process, since many destination countries are facing severe nurse shortages, preferential treatment in obtaining visas and work permits i s given to nurses. In Canada, nurses are fast-tracked through the visa process. In the US, there has been an increase in the number o f visas approved specifically for nurses. In addition, it should be noted that each destination country i s continually undergoing immigration policy reform. In the US, there are immigration policy reform discussions at the time o f writing in the Congress. Since 2007, the UK has been working on dramatically changing i t s immigration procedures. Canada Inflow o ES CARICOM nurses to Canada f The inflow o f ES C A R I C O M nurses to Canada was on average 35 nurses per year between 2002 and 2006. Compared to the UK and the US, the inflow o f ES C A R I C O M nurses to Canada i s relatively small. Detailed information o n inflows i s provided in section F o f the main report and the estimation methodology i s provided in the Methodology Annex. 106 The Nurse Labor and Education Markets in the English-Speaking CARICOM. Issues and Optionsfor Reform Stock o j E S CARlCOMnurses in Canada Using the methods outlined in the Methodology Annex, the stock o f ES CARICOM nurses in Canada was estimated to be 750 nurses in 2001. This represents five percent o f the ES CARICOM nurse stock in the US. Wages Wages per week earned by ES CARICOM nurses working in Canada were calculated using the Canadian Census, for those who have worked more than 40 hours per week and who have worked for more than 24 weekdyear (6 months) in 2000. Table D 1 shows average weekly wages o f migrant nurses compared to their Canadian counterparts. A multilevel analysis was performed to compare the weekly wages between Canadian nurses and migrants nurses, controlling for factors such as age, education attainment, and location o f work. There was no variable available that represented years o f work experience in the Census. This analysis showed that average weekly wages are lower for migrant nurses aged 30 years or older compared to the Canadian counterparts with similar educational attainment and location o f work. The differences in wages for 20 to 29 years old between Canadian nurses and foreign nurses are not statistically different. Figure D1 presents the relationship between age and the estimated weekly wages o f nurses with a Bachelor's degree. Table D1: Summary o f average weekly wages (95% confidence interval) for nurses Wages per week Wages per week Wages per week earned by earned by Canadian earned by Caribbean Migrant nurses from other Nurse ($1 countries ($1 21-29 years 750 (690-810) 30-39 year 970 (910-1030) 550 1210-880) 107 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Figure D1: Estimated Weekly Wages for Nurses in Canada (results o f multivariate analvsis)" I U F o r e i p i N FW *Due to small sample size, ES CARICOM nurses and other foreign-nurses were combined in the analysis Immigration and licensure policies a) Basic process o f migration Foreign-educated nurses face two sets o f challenges, entry regulation and professional registration. As described in the following section, there are four major programs by which nurses can obtain the appropriate immigration status. Additionally, all foreign- nurses have to go through a registration process to obtain proper licensure to practice in Canada. The detailed information o n each process i s described below. 108 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Y Provincial Nominee Programs (PNP) 0 Training Verification Federal Skilled Worker Program 0 Verification of current I ~ I _ I "-" licensure i -- ~ "I Language Proficiency 0 Pass National Temporary Foreign Worker Program Canadian Registered --- Nurses Exam b) Historical changes in immigration policy in Canada In 2002, Citizenship and Immigration Canada (CIC) substantially changed its immigration policy to welcome immigrants based on their general qualification rather than welcoming immigrants engaged in occupations that matched the anticipated future needs o f Canada. However, there are no substantial documents available that specify the impact o f these immigration policy changes on nurse migration. c) Visa/work-permit types There are two employer-driven immigration programs: the Temporary Work Permit program and the Provincial Nominee Program (PNP) (Health Match BC). In addition to these programs, there are two individual-driven programs: the Federal Skilled Worker program and the Live-in Caregiver program. + Temporary Work Permit program In order for employers to be able to utilize the Temporary Work Permit program, employers are required to show that they cannot otherwise fill the position with domestic labor. The temporary work permit i s the work permit under which holders are not allowed to immigrate to Canada permanently. The information concerning the amount o f time a migrant nurse can work in Canada under a temporary work permit i s unclear (no limitation cited in the CIC). According to the Vancouver's health provider's group, Vancouver Coastal Health, it takes up to six months to complete the work permithisa process. In addition, migrant nurses are required to register with the appropriate provincial licensing authority prior to applying for a work permithisa. After a migrant nurse obtains a temporary work permit and an employer obtains the necessary documents from the Human Resources and Skills Development Canada (HRSDC), migrant nurses can apply to the Citizenship and Immigration Canada (CIC) for permanent status. It should be noted that acquiring authorization from the HRSDC i s known to be a major stumbling 109 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform block in the immigration process (Jeans et a1 2005). In addition, migrant nurses who have obtained a temporary work permit gain additional points in the Federal Skilled Workers program (see below) towards permanent residence status. + Provincial Nominee Program (PNP) The PNP i s an immigration program that allows provinces t o select highly skilled immigrants to fill critical areas in the labor market. Migrant nurses are required to apply directly to the specific province in which they will work. They also need a j o b offer from an employer based in the province prior to applying to this program. The PNP selects and nominates potential immigrants for permanent residence. Individuals nominated by a province together with their spouse and dependent children, are eligible to apply for a permanent resident visa from the C I C in the Provincial Nominee class. The CIC gives priority to processing permanent resident visa applications for provincial nominees. In addition, migrant nurses are required to register with the appropriate provincial licensing authority prior to applying for a visa in that province. Provinces consider applications based on needs in that particular occupation. I t has been reported that this process takes no more than nine months (Tsuji). + Federal Skilled Worker program The Federal Skilled Worker program i s an individual-driven program. Thus, it i s not necessary for migrant nurses to have employer support to apply to this program. Individuals are tested based on skill category, work experience, education attainment, age, language skills, arranged employment, and adaptability. Under the Federal Skilled Worker program, the nursing profession does not have any advantage over other professions in obtaining permanent residence status. + Live-in Caregiver program Another widely used program by migrant nurses t o obtain permanent residence in Canada i s the Live-in Caregiver program. This program offers a fast track to applying for permanent residence after working for two years as a care provider for children, elderly persons or persons with disabilities in private homes. However, a reported drawback to this program i s that university educated nurses tend to experience reduced employment opportunities due to not practicing their clinical skills for over two years. As reported by a study conducted on Filipino nurses' experience with immigration to Canada, after entering the country through the Live-in Caregiver program and working as a caregiver for two years, they experienced reduced opportunities to work as a registered nurse because o f the loss o f clinical skills (Pratt 1999). I t should be noted that this immigration rule was modified in 2002 due to lobbying efforts by the Filipino Nurses' Support Group (Bach 2003). d) Preferential treatment for nurses in the visa process Migrant nurses who are provincial nominees are often times fast tracked through the permanent residence application process. 110 The Nurse Labor and Education Markets in the English-Speahing CARICOM. Is.rues and Optionsfor Reform e) Registration and licensure Registration is a process b y which a nurse informs a state or an association that they perform their professional services, so that a governmental body can maintain the l i s t o f nurses in their jurisdiction. Licensure, o n the other hand, guarantees that a nurse has met certain qualification in order to perform a particular service. The first step in the Canadian immigration process is to register with the appropriate provincial licensure authority in order to receive licensure to practice. Once this i s completed, the next step in the process i s to obtain a work permit/visa. A migrant nurse must then pass the National Canadian Registered Nurses Exam (in no more than three attempts). The passage o f this exam i s necessary for a migrant nurse to be considered for licensure. Finally, after obtaining both a work permit/visa and licensure to practice (and if participating in the employer-driven immigration process, the employer has obtained all the necessary documents), a migrant nurse i s then qualified to apply to the CIC for permanent residence status. There i s no centralized credentialing authority in Canada. The entire certification and qualification assessment process i s conducted at the provincial level. f ) Additional clinicahupervised training Canada i s in the process o f developing best-practice guidelines to integrate migrant nurses into the health care delivery system (Simoens et a1 2005). g) Required documents The appropriate licensure body at the provincial level reviews all required documents, such as credentials and language proficiency. It should be noted that there i s no accepted national standardized process for reviewing these documents. h) Costs for migration The cost o f the immigration process i s expensive and can be an inhibitory factor for migrant nurses. This cost includes registration fee, examination fee, language tests, necessary translations, and tuition for possible additional required courses. Often times, migrant nurses are required to have additional training to be able to register and receive licensure to practice. The cost o f additional training can be as expensive as $13,000 (Bach 2003). According a Canadian N u r s e Association report, the overall costs for a migrant nurse partaking in the Canadian immigration process are estimated to range between $1,000 and $20,000 (Jean et a1 2005). It should be noted that costs vary depending o n which type o f work permit/visa i s sought. UK Inflow o ES CARICOM nurses to the UK f The inflow o f ES C A R I C O M nurses to UK was o n average 300 nurses per year between 2002 and 2005. Compared to Canada and the US, the inflow o f ES C A R I C O M nurses to the UK in this period is the largest. This large influx o f nurses reflects efforts by the National Health Service (NHS) to recruit migrant nurses. Detailed information i s 111 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform provided in section F o f the main report and the estimation methodology i s provided in the Methodology Annex. Stock o ES CARICOM nurses in the UK f S Using the methods outlined in the Methodology Annex, the stock o f E CARICOM nurses in the UK was estimated to be 4,750 nurses in 2001. This represents 30 percent o f the ES CARICOM nurse stock in the U S . Wage UK Census did not collect income or wage information. Thus, an analysis was not performed. Immigration and licensure policies a. Basic process o f migration Like entry to Canada, foreign-educated nurses have to overcome both entry regulation and professional registration challenges. There are two major programs to obtain appropriate immigration status as described in the following section. Additionally, all foreign-nurses have to go through a registration process to obtain proper licensure to practice in UK. The detailed information on each process i s described below. Verification of Highly Skilled Migrant Program Training (New: Tier 1) Current Licensure Work Permit Program Verification (New: Tier 2) 0 Language \ J E " . .. . " , . , . . . ... Proficiency Overseas Nurse Program b) Historical changes in immigration policy in the UK The UK i s in the midst o f reforming i t s immigration policy. New immigration programs are in the process o f review and are expected to be adopted by early 2008 (Home Office 2007). The new UK immigration policies are similar to the Canadian Federal Skilled Worker program. 112 The Nurse Labor and Education A4arkets in the English-Speaking CARICOM: Issues and Optionsfor Reform c) Visa/work-permit types There were three immigration programs in the UK that nurses can utilize. However, the UK has planned to overhaul the existing immigration system in 2008, which will integrate these existing programs under one consolidated system (Home Office 2007). + Skilled Worker Program The 2002 Skilled Worker program i s a points-based immigration program, where immigrants are admitted based o n the "points" that reflect their talents and skills. This program i s an individual-driven program; therefore, a migrant does not need advance endorsement from a UK employer. Successful applicants are allowed to work for up to one year in the UK without a work permit, and may apply for an extension o f up to three years. After four years, applicants may apply for permanent residence status. Migrant nurses are qualified to apply for work perniit/visas through the Skilled Worker program. + Work Permit Program Given that the Work Permit program i s employer-driven, an employer must agree in advance to provide employment prior to a migrant nurse applying for a work permithisa. The Work Permit program issues work permits for a specified period o f time. Migrant nurses receive work permits that are valid for two years (Buchan 2002). Occupations that are considered in a state o f shortage in the UK are often times fast-tracked through the work permit application process. According to Buchan' s 2002 report, registered nurses and midwives were categorized as occupations in a state o f shortage. It should be noted that applicants who are citizens o f countries within the European U n i o n are not required to apply for work permits. + Working Holiday Program The Working Holiday program i s valid for citizens o f a Commonwealth country, between the ages o f 17 and 30 years, who are independent (with no family), and who are deemed to have sufficient funds. Working Holiday visas are valid for two years; however, holders o f this visa may only work one o f those two years. Migrant nurses typically do not apply for this type o f visa. d) Preferential treatment for nurses in the visa process As long as the nursing profession i s recognized as an occupation in a state o f shortage in the UK, applications through the current work permit program will continue to be fast- tracked for all migrant nurses. It should be noted that this status i s under constant review. Preferential treatment will cease to exist once the nursing profession i s no longer recognized as in a state o f shortage. e) Registration and licensure The Nursing and Midwifery Council (NMC) i s singularly responsible for UK's registration o f nursing and midwifery professions. Unlike Canada or the United States, no direct examination i s required to obtain licensure in the UK, but nurses' overall credentials are assessed, including their English skills, by the N M C for all nurses. 113 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Since 2005, the Overseas Nurse program (ONP) was added as the part o f registration procedure for migrant nurses who come from countries outside the European Economic Area (EEA). The ONP sets out common entry standards, a compulsory 20 day period o f protected learning for all nurses trained outside the EEA, and where appropriate, a period o f supervised practice (NMC (a)). Migrant nurses who meet the minimum requirements set out by the Nursing and Midwifery Council (NMC) are required to partake in all or part o f the ONP. Migrant nurses must successfully complete the core elements o f the ONP prior to registering with the N M C . In addition to the ONP, since 2007 it i s mandatory for all migrant nurses and midwives to take the British Council's International English Language Test (IELTS), even those migrants whose native language i s English. A potential nurse migrant has to prepare two application forms to the N M C and then participates in the ONP program. For the first application form, a nurse has to provide a certified registration certificate, copy o f passport, birth certificate, marriage or c i v i l partnership licensure and an IELTS score. After review o f the initial application and supporting documents by the N M C , an applicant must complete several additional forms within six months: application form, post-registration experience form, references, transcript o f training, and registration authority/licensing form. After completion o f the application process, migrant nurses are required to participate in the ONP by partaking in a 20 day protected learning course and if appropriate, a period o f supervised practice i s required. f ) Additional clinicalhupervised training Migrant nurses are required to partake in all or a part o f the ONP in order to register with the N M C . g) Required documents The N M C reviews all required documents, such as credentials, language proficiency, proof o f employer endorsement (when applicable), and completion o f the ONP. Within the new UK point system program, proof o f a Bachelor's degree will be the minimum requirement for the tier-I visa. h) Costs for Migration There has been no cost analysis for the immigration process in the UK. us Inflow o ES CARICOMnurses to the US f The inflow o f ES C A R I C O M nurses to the U S was on average 165 nurses per year between 2004 and 2006. The inflow o f ES C A R I C O M nurses to the U S was relatively small during this time period compared to previous time periods. Detailed information concerning inflows i s provided in section F o f the main report and the estimation methodology i s provided in the Methodology Annex. 114 The Nurse Labor and Education hfarkets in the English-Speaking CARICOh4: Issues and Optionsfor Reform Stock o ES CARICON nurses in the US f The stock o f ES CARICOM nurses in the U S was estimated to be 15,550 nurses in 2000. This represents three times the stock o f ES CARICOM nurses in the UK and 20 times the stock o f ES CARlCOM nurses in Canada. Wages Wages per hour earned by ES CARICOM nurses working in the U S were calculated using the 2000 U Census, for those who have worked more than 40 hours per week and S who have worked for more than 24 weekdyear (6 months) in 1999. Data from the U S Census shows that there i s a wide range o f wages earned by nurses. Table D 2 shows the average hourly wages o f migrants nurses compared to their U S counterparts. A multilevel analysis was performed to compare the hourly wages between U S nurses and migrant nurses, controlling for factors such as age, education attainment, and location o f work. There was no variable available that presents years o f work experience in the Census so age served as a proxy. This analysis demonstrated that U S - educated nurses and migrant nurses are paid an equivalent hourly wage. Figure D2 presents the relationship between age and the estimated weekly wages o f nurses with a Bachelor's degree. 50-59 years 25 25 26 60+ years 23 26 25 115 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Figure D2: Estimated H o u r l y Wage for Nurses in the United States (Results o f Multivariate Analvsisb 30 Otl Immigration and licensure policies a) Basic process o f migration Like entry to Canada and the UK, foreign-educated nurses have to overcome both entry regulation and professional registration obstacles. Unlike the other two case study countries, however, nurses' professional qualifications were verified in two separate steps. The detailed information o n each process i s described below. =5 EB-3 Visa (Green Card) CGFNS 0 Certification of education, registration, and licensure 1 0 English Proficiency Test H1C CGFNSExam - 0 f State Nursing Board 0 NCLEX TN (under NAFTA) 3 Nurse Licensure 116 The Nurse Labor and Education Markets in the English-Speaking CARICOM Issues and Options for Reform b) Historical changes in immigration policy in the U S Historically, temporary worker nurse migrants entered the U S on a H-IA visa. Between 1989 and 1995, 30,000 migrant nurses entered the U S on a H1-A visa. Due to resistance from the American Nursing Association (ANA), this process was phased out in 1995. Currently, the H-1B visa (for highly qualified nurses) and the H-1C visa (500 per year and only for limited areas) are the two options available for obtaining a temporary visa. The EB-3 (green card) i s an option for a permanent employment-based visa. c) Visa/work-permit types There are several immigration programs in which migrant nurses can apply to enter the US. The process for obtaining all types o f U S visas for migrant nurses i s employer- driven. Migrant nurses can enter the U S on a permanent employment-based visa (green card). Another option are temporary non-immigrant visas (H-1B and H-1C). In addition, there i s the N A F T A program (TN visa). + EB-3 Visa (Green Card) It i s widely acknowledged that a temporary visa for nurses i s extremely limited in the U S . Therefore many migrant nurses try to enter the U S on an EB-3 visa (Dawson 2005, Arends-Kuenning 2006). In 2005, the U S government granted 140,000 EB-3 visas to skilled workers who had a minimum o f two years work experience (Arends-Kuenning 2006). This i s an employer-driven program, and thus employers are required to f i l e requests for these visas on behalf o f the migrant laborers. In addition, employers are required to prove that they are otherwise unable to fill these positions with domestic laborers. However, since nursing i s recognized under the Immigration and Naturalization Services (INS, now United States Citizenship and Immigration Services (USCIS)) as being in shortage, employers are exempt from showing they were unable to hire U S qualified workers (Neal 2002). In 2005, an additional 50,000 special category permanent W employment-based visas (EB-3 F ) were set aside for nurses (Schaper 2005 in Arends- Kuenning 2006). The process o f obtaining an EB-3 can take a long time, in some cases taking as long as two years (Shusterman 2002). + H-IC H-1C visa i s a temporary visa program set up exclusively for nurses. Each year, only 500 H - I C visas are available, and the number i s limited to 25 migrant nurses per state for small states and 50 migrant nurses for large states (Arends-Kuenning 2006). Migrant nurses can only be brought to hospitals located in regions that are designated as having a shortage o f healthcare professionals. These regions primarily are located in inner cities and some rural areas (Neal 2002). The Department o f Labor (DOL) i s mandated to certify that facilities seeking to import migrant nurses have taken the appropriate steps to recruit and retain U S nurses, and they are not presently experiencing a labor dispute. Legislation i s periodically introduced to Congress to expand the number o f H - I C Visas available (Dawson 2005). The ANA strongly opposes this type o f legislation (ANA 2005). 117 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform + H-1B H-1B visas are granted to highly qualified professionals, such as doctors and engineers. In order to qualify for an H-1B visa, the j o b the applicant seeks must require at minimum a Bachelor's degree. Migrant nursing positions, such as clinical specialists, practitioners and certified midwives, may qualify for an H - 1 B visa (Arends-Kuenning 2006). Also, migrant nurses who are in fields that are in high demand may be issued H-IB visas. It remains uncertain whether the educational restriction for this visa will exclude registered nurses who do not have a Bachelor's degree. For example, Caribbean `diploma nurses' may be excluded from H-1B and H-1C visas (Dawson 2005). However, the I N S S sometimes makes exceptions to this rule based o n the U Department o f Labor's view that there are three educational paths to a nursing degree (a two-year Associate's Degree, a three-year diploma, or a four-year Bachelor's Degree). There are no more than 65,000 H-1B visas issued per year (Arends-Kuenning 2006). + NAFTA (TN Visa) In accordance with the NAFTA agreement, Canada, Mexico, and the U S have removed all quota limitations on temporary migration o f nurses. Professionals, including nurses with university degrees, can apply for a TN visa. However, use o f this agreement has been limited given that there i s limited recognition o f nurse qualifications among the countries and an absence o f standardized licensing requirements. Migrant nurses are still required to obtain a temporary visa to work in the U S (Simoens et a1 2005). Migrant S nurses from Canada and Mexico must pass U requirements for licensure and prove English proficiency. In addition, there has been a cap o n the number o f migrant nurses who can enter o n the TN visa (up to 5,500 per year). These abovementioned factors limit the number o f Mexican nurses who have migrated under the NAFTA program (Aiken et a1 2004). + Licensed Practical Nurses (LPNs) / Nurse Aides Documentation o n the type o f visas used by LPNs and Nurse Aides t o enter the U S i s limited. However, the number o f LPNs and Nurse Aides in the U S i s substantial, especially from Caribbean countries. Given their qualifications and the existing visa programs, LPNs and Nurse Aides only qualify for the EB-3 program. However, the 2005 EB-3 RN program limits EB-3 visas for only registered nurses. d) Preferential treatment for nurses in the visa process The H-1C visa and the EB-3 RN visa are designated for registered nurses. Additionally, employers are exempt from showing proof o f labor shortages, which facilitates the fast- tracking o f EB-3 RN visas. e) Registration and licensure While the final registration process for health professionals in the U S i s regulated at the state level, the U S has created an institution called the Commission o n Graduates o f Foreign Nursing Schools (CGFNS) to screen and certify the credentials o f health professionals who wish to work in the U S . All nurse migrants are required to go through the process with CGFNS before applying for a visa, making this part o f the registration requirement a prerequisite for the immigration process. 118 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Therefore, the first step in the immigration process i s for migrant healthcare professionals to obtain a CGFNS VisaScreen certificate from the International Commission on Healthcare Professions (Extract from CGFNS 2006). As part o f the VisaScreen certificate, applicants have to provide both secondary and nursing education certificates and registration and licensure documents. Also, migrant nurses must successfully pass an English proficiency exam (ICHP 2007a). Caribbean countries that are exempt from this English proficiency exam are Barbados, Jamaica, and Trinidad and Tobago. In addition to the Visascreen certificate, migrant nurses must successfully pass the Commission on Graduates o f Foreign Nursing Schools (CGFNS) exam and the National Council Licensure Examination (NCLEX). The CGFNS certificate i s required to obtain a visa. The successful passage o f the N C L E X i s needed in order to practice in the US. The CGFNS serves as an indicator o f a migrant nurse's ability to pass the N C L E X . In mandating the certificate, the process limits the number o f migrant nurses who apply for a visa. If an applicant can demonstrate "full and unrestricted license to practice professional nursing in the state o f intended employment" (ICHP 2007a), then the applicant is not required to take CGFNS. However, all applicants, without exception, must successfully pass the N C L E X in order to practice in the U S . A new initiative by the National Council o f State Boards o f Nursing (NSCBN) called the Nurse Licensure Compact (NLC) i s a mutual recognition model o f nurse licensure between various states (NLCA 2004). Each state has to enter an interstate compact (such as N L C ) to achieve mutual recognition (NCSBN 2002, 2003). I f a nurse has licensure from the state o f hidher residency that has been admitted to the NLC, then the nurse i s allowed to practice in other states that also are members o f N L C . The map below shows the participating states to N L C as o f January 2007 (NCSBN 2007). States in grey are not part o f N L C . 119 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform f) Additional clinicaYsupervisedtraining Unlike the UK, the U S does not require migrant nurses to partake in any additional clinicalhupervised training. g) Required documents The appropriate licensure body at the state level reviews all required documents, such as credentials, language proficiency, the CGFNS/ICHP VisaScreen Certificate, and successful passage o f the CGNFS and N C L E X . h) Costs for migration Immigration to the U S i s an expensive process. This cost includes visa application fees, registration and licensure fees, VisaScreen and CGFNS certificates, N C L E X fees, and all other processing fees. Typically, it i s either the prospective employer or the migrant nurse who pays for these fees. In addition, private recruiting agencies are often involved in this process. It has been reported that hospitals pay o n average $US 5,000 to $US 10,000 per nurse (three-year contract) to private recruiting agencies (Arends-Kuenning 2006). One benefit o f working with a private recruiting agency i s that they will repay all costs to the hospital if a migrant nurse does not fulfill their contract. Since recruiting and employing migrant nurses i s expensive, it i s the larger hospitals that tend to be involved in this practice (Pizer et a1 1994). 120 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform LABOR ANNEXE: JAMAICANNURSE SURVEY The objective o f the Jamaican Nurse Labor and Education Survey was to identify how and why potential nursing students made their education and labor market decisions. The survey interviewed registered nurses (RNs) who had completed the general nursing program (three years, diploma only) at Excelsior Community College and the Kingston School o f Nursing in the years 1980, 1990, 2000, and 2005. This annex presents descriptive statistics resulting from the survey. Each table or figure is accompanied by a question that each section attempts to answer, followed by a description o f the tables or figures to explain their meaning clearly. In the comparisons between non-migrant and migrant R N s , only the 1980 and 1990 cohorts were studied since no migrants were interviewed from among the 2000 and 2005 cohorts. Description o f the Survey Sample W e identified the residence o f 79 percent (243 R N s ) o f the original sample o f Jamaican nurses. Among those whose residence was identified, 53 percent (161 R N s ) completed the interview. Response rates were higher among the more recent cohorts o f graduates (Table El). Samplt? 1980 1990 2000 2005 Total Original Sample 92 54 73 89 308 243 Identified Residence 44 51 66 87 (79%) 21 30 40 70 161 Interviewed (response rates %) (23%) (56%) (54%) (79%) (53%) Individual Characteristics o f R N s What are the social and demographic characteristics o the RNs? f Ninety-nine percent o f the nurses who were interviewed were women (Table E2). The average age o f graduation for these R N s was 25 years old. Among the 1980 and 1990 cohorts, nearly 60 percent o f R N s were married. H a l f o f the R N s from the 2000 cohort were married, and about one-third o f the R N s in the 2005 cohort were married. R N s from the 1980 cohort had an average o f two children. R N s from the 2000 cohort had an average o f one child (Table E3). 121 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform I Female I 154 (99Yo) I I Male I 1(1%) I I Total I 155 I Table E3: Mean Age, Mean Age at Graduation, Percentage o f Married Respondents, and I_-- 1)escriptivr Mean Age (in 2008) 1980 53.1 I990 __ 40.7 -. 2000 33.3 2005 30.1 1 Mean Age at Graduation 25.8 22.7 25.3 27.1 YOMarried 57% 57% 50% 32% I Mean Number o f Children I 1.9 I 1.6 I 1.1 1 0.6 I Where do RNs live and how many live abroad? Among the sample o f R N s whose residence was identified, 31 percent were living abroad, o f whom 77 percent were living in the U (Table E4). O f the sample o f nurses S who were interviewed, 17 percent were living abroad, o f whom 96 percent were living in the U S (Table E.5). Higher percentages o f the older graduation cohorts lived abroad than among the younger cohorts. Among those interviewed, Seventy-one percent o f the R N s in the 1980 cohort lived abroad and 43 percent o f the 1990 cohort lived abroad. N o R N s from the 2000 and 2005 cohorts lived abroad at the time when the interviews were conducted (Table E5). Bahamas I 0 I 1 I 0 I o 1 1 I Bermuda I 1 I 1 I 0 I 0 I 2 I Canada I 4 I 1 I 0 I 0 I 5 I EuroDe I 0 I 1 I 0 I 0 I 1 I UK I 1 I 3 I 1 I 0 I 5 I USA I 32 1 24 I 4 I 0 I 60 I Other I 0 I I 0 I 3 I 1 I I 4 I Total 44 51 66 87 24 8 38 31 8 1 78 Total Abroad (YO) (86%) (61%) (12%) (1%) (3 1%) 122 The Nurse Labor and Education Markets in the English-Speaking C'ARICOM: Issues and Optionsjor Reform Jamaica 6 17 40 70 133 Bermuda 1 0 0 0 1 USA 14 13 0 0 27 Total 21 30 40 I 70 161 15 13 28 Total Abroad 0 0 (7 1Yo) (43%) (17%) Do migrant and non-migrant RNs d$er in terms of their parent's educational attainment? The responses o f the R N s in the 1980 and 1990 cohorts revealed that the highest education degree obtained by at least one o f their parents was a high school diploma. In total, 44 percent o f R N s had at least one parent who completed secondary education. None o f their parents obtained a tertiary education degree. Fifty percent o f non-migrant R N s had at least one parent who completed secondary education compared with 39 percent o f migrant R N s (Table E6). Table E6: Highest Educational Attainment by Parent o f R N s from the 1980 and 1990 Cohorts Class Rank Jamaica Abroad Total Primary Incomplete 2 1 3 Primary Complete 8 11 19 Secondary Incomplete 1 5 6 Secondary Complete 11 11 22 Total 22 28 50 What are the top two reasons given by the RNs for entering nursing school? The top two reasons that the R N s gave for entering nursing school were the ability to help other people (79 percent or 125 out o f 157 RNs) and j o b security (32 percent or 51 out o f 157 RNs). The chance to work abroad was the reason that was chosen least often (Figure El). 123 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Figure El: Top Two Reasons Given for Entering Nursing School (as Percentage of R N s Interviewed) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Income Are the RNs the primary income earners in their household? Among non-migrant R N s from all four cohorts, 92 percent contributed to at least half o f their household income (Figure E2). Among non-migrant R N s from the 1980 and 1990 cohorts, 95 percent contributed to at least half o f their household income. All migrant R N s contributed to at least half o f their household income (Figure E3). 124 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Figure E2: Contribution o f Individual Income to Household Income by Non-migrant R N s ( R N s Interviewed) Figure E3: Contribution o f Individual Income to Household Income by Migrant and Non- migrant R N s.... ,,,,,,,,,,,,,,,,,. and 1 ,,,- . ,,,, , , (1980 ,,,,,, ,,,,,,,,.... ................ ................ ~" ~ _.." s Interviewed) ohorts o f R N ,,,,,,,,~-~~~,,... _, ,... 70% 125 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform How do the individual incomes o non-migrant and migrant RNs compare? f Migrant R N s who were working in the U S earned higher incomes than non-migrant R N s . Sixty-three percent o f migrant R N s who were working in the U S earned $70,000 or more a year. The highest income bracket for the non-migrant R N s was between $15,000 and $24,999, and only 41 percent o f them had earnings in this range (Figure E4). Figure E4: Individual Income of Migrant and Non-migrant F t N s (1980 and 1990 Cohorts o f R N s Interviewe x_n I 1 x x__ 20 Individunf Annual I ncame S Note: The Jamaican income ranges that were converted into USD are slightly different from the U income ranges, but similar enough for comparison. How do the individual and household incomes o non-migrant and migrant RNs f compare? The households o f migrant R N s who were working in the U S had higher overall incomes than the households o f non-migrant R N s . Ninety-six percent o f the households o f migrant R N s had incomes o f more than $50,000 a year, o f which 12 percent had incomes o f more than $140,000 a year. In comparison, only one household o f a non-migrant RN received over $50,000 a year. Over h a l f o f the households o f non-migrant R N s had household incomes in the range o f $10,000 to 19,999 per year (Figure E5). 126 The Nurse Labor and Education Markets in the English-Speakrng CARICOM. Issues and Options for Reform Figure E5: Household Income o f Migrant and Non-migrant R N s (1980 and 1990 Cohorts o f R N s Interviewed) B I 15 I flouss?holdAnnual incorns? J a fs1s lC,a u5 I Note: The Jamaican income ranges that were converted into USD are slightly different from the US income ranges but are similar enough for comparison. Employment How large is the inactive supply o RNs? f Among the R N s who were interviewed, 97 percent stated that they were working as a nurse, o f whom 98 percent were working full time. Only one respondent reported working full time but not as a nurse. The remaining three respondents who were not working as nurses were either retired or studying (Table E7). Full-time 152 1 153 Part-time 3 0 3 Retired 0 2 2 Studying 0 1 1 Total 155 4 159 127 The Nurse Labor and Education Murkets in rhe English-Speaking CARICOM: Issues and Options for Reform How many o the inactive RNs are migrants and non-migrants? f Among the 13 1 non-migrant RNs, 126 (98 percent) were working full time as nurses, two were working part time as nurses, one was working full time in another profession, one was retired, and one was studying (Table E8). Among the 28 migrant R N s , 26 (93 percent) were working full time a nurses, one was working part time as a nurse, and one s was retired (Table E9). Table E8: Employment Status in the Nurse Labor Market o f Non-migrant R N s (Non- 1 1 0 you Hork as a Nurse? ----- -. --. " -- .. -___ . j Employnieiit Status Yes No l-otal I Full time 1 126 I 1 I 127 I Part time 2 0 2 Retired 0 1 1 Studying 0 1 1 Total 128 3 131 I Fulltime I 26 I 0 I 26 I 1 Parttime I 1 ~~ I 0 ~~ I 1 I Retired 0 1 1 Studying 0 0 0 Total 27 1 28 Are nurses working more than one j o b ? Among the R N s who were working full time as a nurse, 9 percent had multiple jobs, o f which 82 percent were nursing jobs. Seven percent o f non-migrant R N s had multiple jobs compared with 15 percent o f migrant RNs. Of those who had multiple jobs, 75 percent o f non-migrant R N s were working as nurses in their second job, while all migrant R N s were working as nurses in their second job (Table E10). 128 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Rejortn Have multiple ,Jabs - Abroad Total Yes 9 4 13 (7%) (1 5%) (9%) No 117 22 139 Total 126 26 152 Subtotal with a second Job as a nurse 6 3 9 (%I (75%) (1 00%) (82%) Education To what extent did RNs finance their own nursing education? Among all o f the R N s interviewed, 18 percent stated that they had paid for some part o f their tuition for nursing school. The percentage o f R N s who paid for their own tuition increased with each year o f graduation. Only 5 percent o f the R N s from the 1980 cohort paid for their education compared with 27 percent o f the 2005 cohort. Forty-six percent o f all R N s interviewed reported paying for their living expenses while in nursing school. Again, the percentage o f R N s who paid their living expenses increased by graduation cohort, from 14 percent o f the R N s from the 1980 cohort to 60 percent o f the R N s from the 2005 cohort. Almost all R N s reported paying for the materials for nursing school (Table Ell). The R N s reported paying an average o f $520 each year for some part o f their education and living expenses. There was a substantial difference between the annual amounts paid by the R N s from the 1980 and 1990 cohorts and the amounts paid by the R N s from the 2000 and 2005 cohorts (Table E12). Did you pay far,..? 1980 1990 2000 2005 Total Yes No Yes No Yes No Yes No Yes No 1 4 4 19 Tuition 28 131 (5%) 2o (13%) 26 (11%) 34 (27%) 51 (18%) 3 8 21 41 Living Expenses 73 84 (14%) l8 (28%) 21 (54%) l8 (60%) 27 (46%) 19 30 36 70 155 Education Materials (90%) (100%) O (95%) (100%) O (97%) Table E12: Average Annual Amount of Education Costs Paid for by Students at the Time of their Education ( R N s Interviewed) Mean ~ d u ~ Cost t ~ ~ ~ a 2005 Total Paid by Students (USD} Mean $9 1 $165 $52 1 $736 $518 (SD) ($252) ($375) ($736) ($397) ($460) 129 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform How much would RNs have been willing to pay for their nursing education? In the survey, the R N s were asked what was the maximum amount o f tuition that they would have been willing to pay for nursing school per year. They were given three options: 1) out o f pocket, 2) with an option to receive a bank loan with a low interest rate and no collateral that would have to be paid back within 10 years after graduation, and 3) with an option to receive the same loan and a guaranteed job in Canada, the UK, or the U S . Regardless o f their place o f residence, R N s reported that they would have been willing to pay a larger portion o f their education if there had been the option o f a loan and o f a guaranteed job in one o f the three countries mentioned. Migrant F W s who were working in the U S would have been willing to pay out o f pocket five times more than non-migrant R N s , seven times more if they had had the option o f a loan, and 12 times more if they had had the option o f a loan and o f a guaranteed job in the one o f the three countries. Non-migrant R N s reported that they would have been willing to pay an average o f $1,220 out o f pocket, $1,510 with the option o f a loan, and $1,800 with the option o f a loan and o f a guaranteed job in Canada, the UK, or the US, whereas the migrant R N s working in the U S would have been willing to pay an average o f $5,830 out o f pocket, $10,040 with the option o f a loan, and $2 1,940 with the option o f a loan and a guaranteedjob (Table El3 and Figures E6 and E7). Table E13: Willingness to Pav for Nursing Education ( R N s Interviewed) LOill LoanandJob Country o f Residence __ (P1 77n (USD) c1 i 1 n c i onn 9 1 ,LLV J)l,JIV 91,OUU Jamaica (SD) ($1,050) ($1,170) ($1,490) I $5,830 $10,040 $2 1,940 U S (SD) ($10,390) ($12,15 0) ($3 1,960) 130 The h'urse Labor and Education Markets in the English-Speaking CARICOM Issues and Options for Reform Figure E6: Distribution o f Willingness to Pay for Nursing Education (Non-migrant R N s Interviewed) 35% 30% 25% 20% 15% 10% 5% n 0 Loan Wi I Ii ngness to Pay for Nursing Education (USD), RNs n J a m i c a Loan+Job Figure E7: Distribution o f Willingness to Pay for Nursing Education (Migrant R N s Interviewed1 80% 70% 60% 50% 40% 30% 20% 10% 0% m 0 n USA 13 1 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Afer completing the general nursing program, did the RNs continue their education and obtain higher degrees? Approximately half (53 percent) o f the F W s interviewed continued their nursing education and obtained an advanced degree after graduating from the general nursing program. O f the higher degrees obtained, 5 1 were Associate and Specialist Training degrees, 14 were Bachelor's degrees, and 5 were Master's degrees. The majority o f nurses who graduated prior to 2005 have obtained an advanced degree (Table E14). Among the 1980 and 1990 graduation cohort, 93 percent o f migrant R N s obtained an advanced degree compared with 96 percent o f non-migrant R N s (Table E l5). -- _.__I_.- Year of Gradualion . Advanced Nursing Degree 1980 - __- ______ -__ - . __ None 2 (1 0%) 1 (3%) 6 (15%) 67 (96%) 76 (48%) 1 Unspecified 0 3 9 2 14 Associate Degree and Specialist 1 Training 9 I 1 7 I 2 4 1 1 1 5 1 Bachelor Degree 8 6 0 0 14 Master Degree 2 3 0 0 5 Subtotal with advanced nursing 19 (900/) 29 (97%) 33 (85%) 3 (4%) 84 (53%) degree (%) Total 21 30 39 70 160 Table E15: Type o f Advanced Degree Obtained by Country of Residence (1980 and 1990 I Unspecified 2 I 3 I Associate Degree and Specialist Training 1 Bachelor Degree 1 3 1 11 11 I I 26 14 I 1 Master Degree - 1 3 1 I 2 I 5 I Subtotal with advanced nursing 22 (96%) 26 (93%) 48 (94%) degree (YO) 1 Total I 23 I 28 I 51 I 132 The Nurse Labor and Education Markets in the English-SpeakingCARICOM: Issues and Optionsfor Reform How did RNsJinance their advanced degree programs? Fifty-six percent o f the R N s stated that scholarships and grants funded their continued education. Twenty-one percent reported paying out o f pocket for their continued education. Among the R N s who were trained in Jamaica, 68 percent funded their continued education with scholarships and grants and 14 percent paid out o f pocket. Among the R N s who were trained abroad, 44 percent paid out o f pocket for their continued education (Table E l 6). Self 9 (14%) 8 (44%) 17 (21%) Other 3 (5%) 6 (33%) 9 (1 1%) Bonded by Government 7 (11%) 0 (0%) 7 (9%) Bank Loan I I 1(6%) I 10%) I Spouse 1(2%) 0 (0%) 1 (1%) Total 62 18 80 How long after graduating >om the general nursing program did the R N s obtain their advanced degrees? Among the 1980 cohort, 68 percent o f those who continued their education and obtained higher degrees did so 15 years or more after they graduated from the general nursing program. Even among the 1990 cohort, approximately 26 percent o f those who obtained higher degrees waited 15 years or more to do so. In the 2000 cohort, 80 percent o f the graduates continued their education, o f whom all did so within eight years o f graduating. Also, only three out o f the 70 R N s who graduated in 2005 had continued their education by the time o f the survey (Table E17). Years 1980 1.990 2000 2005 Tota t ~ within 5 y r s 0 2 5 3 10 5 to 9 yrs 1 9 27 0 37 15 y r s or more 13 7 0 0 20 Total 19 27 32 3 81 133 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Migration Are there any differences between non-migrant and migrant RNs in terms o how they f ranked themselves in their class? Forty-five percent o f non-migrant R N s said that they were in the top 10 percent o f their class, while 67 percent o f migrant R N s said that they were in the top 10 percent. N o one claimed to be in the bottom 50 percent o f their class (Table E18). Table E18: Class Rank of Non-Migrant and Migrant R N s (1980 and 1990 Cohorts o f R N s Interviewed) Class Rank Non- Migrdnt !Migrant Total __- I Top 10% 10 18 28 Top 30% 8 8 16 Top 50% 4 1 5 Bottom 50% 0 0 0 Total 22 27 49 Are there any differences between non-migrant and migrant RNs in terms oftheir marital status? O f the R N s from the 1980 cohort, 67 percent o f non-migrant R N s were married compared with 53 percent o f the migrant R N s . The same trend was evident among the 1990 cohort, in that 59 percent o f the R N s who were living in Jamaica were married, while 54 percent o f migrant R N s were married (Table E l 9). Table E19: Percentage of Non-migrant and Migrant R N s who are Married (1980 and 1990 Graduation Year Are there any differences between non-migrant and migrant RNs in terms o the f percentage who had children before graduation? O f those from the 1980 cohort, 33 percent o f non-migrant R N s had a child before graduating compared with 27 percent o f migrant R N s . O f those from the 1990 cohort, 6 percent o f the non-migrant R N s had a child before graduating, whereas no migrant RN had a child before graduating (Table E20). 134 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform Y with Children Before Graduation a Graduation Xcar ~ N ~ R Migrant - M R 1980 33% 27% 1990 6% 0% How many years did the RNs work in Jamaica before migrating? The migrant R N s who graduated in 1980 worked in Jamaica for an average o f six years before migrating to the US. The migrant R N s who graduated in 1990 they worked in Jamaica for an average o f almost 10 years before moving to the U S . N o R N s from the 2000 and 2005 cohorts were living abroad at the time o f the survey (Table E21). 1990 16.1 9.6 2000 6.8 12005 I 2.0 I I I Did the RNs migrate on a permanent or a temporary basis? f O the RNs who had ever lived abroad, did they work and ifso in whatprofessions? O f the 126 R N s who were living in Jamaica at the time o f the interview, only six R N s (5 percent) reported ever living abroad (Table E22). O f these R N s , three R N s identified the U S as the country in which they had lived the longest (an average o f eight years) (Tables E23 and E24). Two-thirds o f the nurses who had ever lived abroad reported currently working in the US, and they all worked as nurses (Tables E25 and E26). O f the R N s interviewed who were living abroad at the time o f the interview, 27 lived in the U and one in Bermuda (Tables E22 and E25). On average, these R N s had lived in S the U S for over 15 years. While living in the US, they had all worked as nurses (an average o f 15.1 years working as a nurse) (Table E27). 135 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform - Yes 6 1 27 34 Total 126 1 27 154 Table E23: Foreign Countrv Lived in the Loneest ( R N s Who Had Ever Lived Abroad) ES CAFUCOM 3 1 0 4 UK 0 0 3 3 1 Total I 6 I 1 I 27 I 34 I UK 4.8 USA 8.0 15.3 I Yes I 4 I 1 Total 6 1 27 34 I Yes I 4 I 1 136 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform Table E27: Average Number of Years Worked as a Nurse Abroad (RNs Who Had Ever Lived Ahroad) ES CARICOM 1.o 10.0 UK 4.8 USA 8.0 15.1 D i d the migrant nurses know anyone in their destination country before they migrated? Eighty-eight percent o f the R N s who had ever lived abroad knew at least one person living in their destination country before migrating. Approximately 90 percent o f the R N s who had migrated to the U S knew at least one person living in the area before migrating (Table E28). The majority o f R N s (80 percent) migrated either to Florida or New York (Table E29). Did you know at least one person in the destination country er ~ ~ o u ~b t d abroad 5 No Yes Total ES CARICOM 1 3 4 UK 0 3 3 I USA I 3 I 24 I 27 I I Total I 4 I 30 I 34 I 137 The Nurse Labor and Education Markets in the English-Speakng CARICOM, Issues and Options for Reform What was their rationale for migrating? How did salaries, career development prospects, and better education opportunities for their children influence their decision to migrate? Ninety-four percent o f the R N s who had ever lived abroad stated that earning a better salary was one o f the reasons why they chose to migrate, while 81 percent reported that better work and career development opportunities were important factors in their decision to migrate. Sixty percent o f the R N s who had ever lived abroad stated that providing a better education for their children was an important reason why they migrated (Table E30). Better Salary 2 (6%) 29 (94%) 31 Better career development and 6 (19%) 25 (81%) 31 work opportunity Better work and career 12 (40%) 18 (60%) 30 development opportunities Do the RNs who have never lived abroad intend to migrate? What are their reasons for not migrating? O f the nurses who have never lived abroad, 81 percent reported that they had considered migrating. O f the 2000 and 2005 nurse cohorts who were in bonding scheme, over 80 percent o f both cohorts reported that they had considered migrating (Table E3 1). Table E31: R N s in Jamaica Who Have Considered Migrating ( R N s Who Had Never Lived Abroad) r Graduation Cohort I I 1990 I 9 (75%) I 3 I 12 I 2000 30 (83%) 6 36 2005 53 (80%) 13 66 Total 96 (81%) 23 119 The most common answer given by R N s to the question about why they had not yet migrated or did not intend to migrate was their limited knowledge about migration opportunities (45 percent). . Other answers given were that they did not want to be separated f i o m their family (17 percent) and that they were currently bonded by the government to work in Jamaica (13 percent). Only one RN stated that he or she had no interest in migrating (Table E32). 138 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Optionsfor Reform in JamaicalRNs Who - Table E32: Reasons for Remaining__ - __ ___ - - - . ___ - - _ _ Had Yever Lived Abroad) __r------- - _I Reasons for Remaining in the Home Countrj ~ Total ~ Have no knowledge about opportunities to migrate 64 (53%) Do not want to leave family 16 (13%) Others 13 (11%) Bonded 12 (loo/,) I Like my home country I 9 (8%) I Want to gain more experience before migrating 3 (2%) Like my job 2 (2%) Generally not interested in migrating 1 (1%) Total 120 Do the migrant RNs intend to return home? For those who said that they would return, would they work as nurses in Jamaica? O f those R N s living abroad, 71 percent said that they intended to return home (Table E33). O f those who said that they intended to return, almost half reported that they would not work as a nurse in Jamaica. The main reasons given for wanting to return home were: 1) to contribute to the health sector at home; 2) to retire at home; and 3) family obligations. The main reasons given for not wanting to return home were: 1) high levels o f crime and concern for safety; 2) poor working conditions; and 3) poor standards o f living for retirement (Table E34). Table E33: Intention o f Returning Home ( R N s Who Are Living Abroad At the Time o f Interview) Country of Residence Do you intend to go back your home country? Yes No Total Bermuda 1 (lOOY0) 0 1 us 16 (70%) 7 23 Total 17 (71%) 7 24 Table E34: Intention o f Returning Home and Working as a Nurse (Migrant R N s Who Country of Residence D o j o u intend to work as a iiurse upon return? ... - . . . .. . - ___ __ Yes No Total _. Bermuda 1 (100%) 0 1 us 8 (50%) 8 16 Total 9 (56%) 8 16 139 The Nurse Labor and Education Markets in the English-Speaking CARICOM: issues and Optionsfor Reform Do the migrant RNs send remittances? Among the migrant RNs, 79 percent stated that they sent home remittances, which on average amounted to $2,800 a year (Table E35 and Table E36). I 1990 I 11 (85%) I 2 I 13 I 2000 0 0 0 2005 0 0 0 Total 22 (79%) 6 28 Note: Those who send money to their own saving account are not considered to be sending remittances. 1 I Gritduation Cohort Amount o f Annrwl Hcniitlances(US0) ___I -.._..___I_ 1980 $2,600 1990 $2,900 I 2000 I -- I Satisfaction Are the RNs satisfied with their current j o b in terms o salary, work environment, and f work and career development opportunities? Are the migrant RNs more satisfied with their salaries, work environment, and work and career development opportunities than the non-migrant RNs? In terms o f salary, 53 percent o f non-migrant R N s stated that they were very dissatisfied, whereas no migrant RN stated that they were very dissatisfied. N o non-migrant R N s stated that they were very satisfied with their current salary, whereas 19 percent o f migrant R N s stated that they were very satisfied (Table E37). In terms o f work environment, 16 percent o f non-migrant RNs stated that they were very dissatisfied, and no migrant RN stated that they were very dissatisfied. Three percent o f non-migrant R N s stated that they were very satisfied with their work environment, whereas 15 percent o f migrant R N s said that they were very satisfied. The work 140 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues arid Options for Reform environment was defined in the survey by such factors as the number o f patients per nurse, the number o f hours worked per week, the safety o f the work environment, and being respected within their work community (Table E37). In terms o f work and career development opportunities, 7 percent o f non-migrant R N s stated that they were very dissatisfied, and no migrant RN stated that they were very dissatisfied. Seven percent o f non-migrant RNs stated that they were very satisfied with the work and career development opportunities at their current job, whereas far more - 48 percent - migrant R N s stated that they were very satisfied (Table E37). Table E37: Satisfaction with Salary, Work Environment, and Work and Career Note VS= Very Satisfied, S= Satisfied, D = Dissatisfied, and VD= Very Dissatisfied Were migrant RNs satisfied with their j o b prior to migrating? In terms o f salary, o f those who are living abroad at the time o f the interview, 91 percent reported being satisfied with their salaries that they were earning at their current j o b abroad, and only 32 percent said that they were satisfied with the salary that they earned at their last j o b prior to migrating (Table E38). In terms o f work environment, o f those who were living abroad at the time o f the interview, 86 percent reported being satisfied with the work environment o f their current j o b abroad, whereas only 55 percent o f them said that they had been satisfied with the work environment o f their j o b prior to migrating (Table E38). In terms o f work and career opportunities, o f those who were living abroad, 91 percent reported being satisfied with the work and career development opportunities available at their current j o b abroad whereas .just 50 percent o f them were satisfied with the opportunities available at the j o b that they held prior to migrating (Table E38). 141 The Nurse Labor and Education Markets in the English-Speaking CARICOM: Issues and Options for Reform 'able E38: Satisfact n with Salary Before and After M ration ( R R s Interviewed) Ikfore Migration After Migration - -. . 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