Indian Nurse’s Diaspora in Global Health Care; Uncovering the Key Findings About Migration of Nurses from Indian Perspective: A Review

There is no doubt that consequences of health workforce migration are serious for any developing country. The world's largest health care migrating population is from India. India has a population of 1.38 billion, about 17.7% of the world’s population and we, as a nation, are struggling to prepare future-ready health care professionals and our own health professionals’ needs are not met. However, large numbers of Indian nurses migrate to developed countries due to numerous factors. Economic factors are considered main force for migration, but not always purely responsible, as nurses look for safety, security, respect, and dignity of their profession. This scoping review is employed to find causes, consequences, and strategies related to international migration of Indian Nurses.


BACKGROUND
India is the country with enormous growth in its scope to produce health care professionals 1 . Nurses are the backbone of every health care system and adequate numbers of nurses are required to run any health care system smoothly. According to Union Ministry of State Heath and Family Welfare (2020), there are over 30 lakh nurses in the country with the nurse population ratio around 1:658 as per population estimate of 1.35 Billion 2 . However, India still faces challenges of adequate availability of nurses in health care sector.
On Contrast, India is one of the biggest source for migrant nurses across globe. About 56,000 nurses trained in India were working in United Kingdom, the United States, Australia and Canada in 2016, which was approximately equivalent to 3 percent of the total nurses registered in India; however, this number has been escalated more in recent years 3 .
Global movement of nurses from India is an ancient phenomenon. However, due to increased shortage of nurses in developed countries, migration has become more obvious 4 . There is shortage of nurses worldwide. Globalization, demand-supply dynamics, asymmetrical development and improved connectivity with the better information flow, communication and decreased travel expenses have vitalized the international migration of nurses 5 . According to a survey, conducted by World Health Organization, it was revealed that 77% of developed nations are experiencing shortage of nurses and nearly all these countries are relying in abroad trained nurses to ease the situation 6 . Thus, global migration of nurses, especially from developing nations is the focus of researchers and health policy makers that has gained more consideration lately 7 . Main consequences of nurses' migration can be seen as benefits in terms of improved knowledge and skills transfer, technology advancement, magnificent wages, professional upliftment and improved living standards of nurses and disadvantages can also be there, which are related to reduced number and uneven distribution of nurse's workforce at source country 8 . International migration of Indian nurses is believed to be associated with loss of cost and human capital, but it has not been yet fully analysed in aspect of overall statistics and policy significance.

TRENDS IN MIGRATION OF INDIAN NURSES
Since 1970, the number of international migrants from India has magnified in number and nurses are the main components of this migratory flow 7-8 . India is a major supplier of migrant nurses to globe. According to HSE (2003) and NMC (2005), Philippines once the topmost source of migrant nurses to the United Kingdom and Ireland is now replaced by India since the year of 2005 9-10 .
The migration of Indian nurses can be first discovered in 1970's. In initial time, a few nurses from India used to migrate because likelihood of employment and earning were high in foreign countries especially GULF countries 11 . This helped the nurses to send remittances back their home 12 .
In post-1980's transfer to mass global migration of Indian nurses was recorded, especially from the Kerala state. According to Nair & Percot (2007), majority of the nurse migrants during 1980's in the United Kingdom were represented by Christian Nurses of Kerala 13 .
During 2000's, nurses' recruitment was mainly targeted from three recruitment hubs i.e., Bangalore, Kochi and Delhi to countries like the Gulf nations, the United Kingdom, the United States, Ireland, New Zealand, Singapore and Australia. With time, the main hotspot of migration has been shifted to north India especially in Punjab. Punjab has played a leading role in nurse training and migration to countries like Canada, Australia, the United States and the United Kingdom 14 .
Trend in migration of Indian nurses to the major destination nations has been changed in recent years. The percentage of migrant Indian nurses going to Gulf countries like Saudi Arabia has declined to 22% (2016) from 32% (2011). Also, the percentage of migrant nurses going to the United States is seen decreased to 6% (2016) from 12.2% (2011), while the nurses moving to Canada raised from 3.3% (2013) to 5.5% (2016). Australia has also been emerged as choice of nurses for migration in above said years. Thus, this migration pattern indicates that there is shift from Gulf countries to countries like Canada and Australia has been observed. Indian nurses also comprise a significant number of foreign trained nurses in New Zealand, Ireland, and the United Kingdom 8 .
A number of nations have encouraged migration of nurses in recent period. For example; a fast-tracked visa for health care professionals was announced by United Kingdom in 2019 to meet shortages of health care workforce in National Health Service (NHS) 3 . A large number of young Indian nurses are joining NHS so that they can work in the United Kingdom.

DESTINATION COUNTRIES FOR MIGRATION OF INDIAN NURSES
Indian nurses focus on two alternatives amongst the destination countries for migration. They can take employment in the Gulf nations or can migrate to industrialized nations such as United Kingdom, Australia, Canada, United Kingdom, Ireland, etc. A nurse should have a minimum working experience of two years to take employment in Gulf nations. Also, they need to appear for an interview which can be either face to face or even telephonic. However, nurses need to qualify some examination as CGFNS (United Kingdome, Canada, Australia, Ireland and New Zealand), NCLEX (United States), and IELTS (United States) for working in the developed nations 4,8 .
Therefore, initially many of Indian nurses used to migrate to the Gulf nations as migration criteria are simpler. It is easier and economical process to move to Gulf countries than industrialized nations. The most preferred nations by migrant nurses are the United Arab Emirates, Qatar, Oman, Bahrain and Kuwait among the Gulf nations, as these nations provide lucrative wages and better quality of life. Least preferred nations are Yemen and Saudi Arabia by the migrant nurses of India. The Indian nurses may encounter religious and social curtailments in some Gulf nations, especially in Saudi Arabia. Also, there is no provision of permanent citizenship, or owning a house, or land and fewer opportunities are available for children's education in the Gulf countries. Married female nurses' migrants also cannot bring their family to Gulf countries. Therefore, Indian nurses prefer to seek employment in the developed nations then Gulf nations in recent years 15 .

FACTORS RESPONSIBLE FOR MIGRATION OF INDIAN NURSES
The factors that motivate young nurses to opt for migration include push and pull factors. Push factors are the agents in source country that force people to emigrate. Pull factors are the forces from destination countries that allure professionals from other countries. Pull and push factors are often opposite characteristics of same phenomena in source and destination countries 16 .
The major push factor for Indian nurses' migration to the other countries is lack of availability of jobs with decent wages in India. Low salaries and profuse workload also seem to be major challenges for nurses. Though salaries have improved with the implementation of the recommendations of the seventh Pay Commission in 2016, the salaries and allowances are still much lower than those offered in developed countries. Also, seventh pay commission is not im-plemented in all the states. Addition to this, there is few job opportunities in public sector as number of vacancies produced each year are really less as compared to number of new nurses completing their course. Putting light on private sector, nurses are underpaid and are forced to work overtime. The nurses are paid in the range of INR 3000-15000 per month in private sector, which is not sufficient. It appears that migration becomes a much more appealing option as compared to joining the public and private health workforce in India. The prospect of going abroad on a good salary is one of the key factors influencing youngsters' decision to choose nursing pro-fession 11,15-17 . Moreover, the job description of nurses is also not well defined in many health care institutions in India as compared to other countries. Well written job roles, functions and responsibilities attract the nurses more as compared to poorly defined ones.
Those who prefer to go to other countries are also fascinated by pull factors such as the lifestyle there as well as the dignified working conditions in those countries. Figure 1 enumerates the number of factors responsible for migration of Indian nurses to overseas.

CHARACTERISTICS OF MIGRANT NURSES
The characteristics of the Indian nurses who migrate to overseas are discussed by some researchers. The literature found related to features of nurses who migrate or have intension to migrate is examined below.
Age: Age is one of the vital factors to affect one's intention to migrate. Usually, the young are more mobile than the older nurses. A study done by Oda H (2018), reported that the ratio of nurses' having intentions to migrate abroad was 64.7% among the young nurses (age less than 30 years) while it was just 11.3% among the nurses above 30 years of age with a statistically significant difference at the 1% level 18 .
Gender: Nursing is a female dominating profession. However, much literature specifying the gender characteristics of migrating nurses is not available till now.
Marital status: The marital status is also one factor that restricts one's migration. Nurses who are single/divorced/widows tend to have a higher intension to migrate. Unmarried nurses usually have more mobility than married ones as the latter require looking after of their family, reducing their migration. Also, a single nurse working overseas is considered as a ticket for the groom to move foreign country.
Religion: According to Nair and Percot (2007), traditionally majority of international nurse migrants from India were Christians 15,18,19 . The job of nurses was previously considered low status, but with improvement of socioeconomic status of nurses and prospect of international migration, nursing profession is now viewed as a ticket to success. Therefore, regardless of their religion, individuals are pursuing nursing practice and thus minimizing divergence between various religions.
Type of workplace: There is a strong tendency that nurses practicing in corporate institutions have intentions to move overseas. A study done by Oda H (2018) reported that 70% of nurses in private hospitals say that they have intentions to go abroad while that ratio of nurses in public hospitals who want to move abroad is just 4.0%. The difference is statistically significant at the 1% level [18]. According to Thomas (2006) who examined the intention of international migration among Delhi-based nurses, reported the same data 11 . It is also consistent with the findings of Walton-Roberts (2017) and Timmons et al. (2016) 3,20 . As nurses working in public institutes are getting better pay scales and having a relaxed working atmosphere and adequate facilities, this can also be rationale of not having much intention to move among nurses of Government institutions 21 .
Type of educational institution: The relationship between the type of nursing school (either government-run or private one) and the intention to migrate is similar to type of workplace. According to Oda H (2018), about 70% of nurses graduated from the private school have intentions to migrate and just 9.5% of alumni of the government-run nursing institutes have so 18 . Also, nurses have to qualify competitive entrance exams to take an employment in the government facilities which are quite complex for the nurses graduated from private educational institutes.
Geographical Areas: Historically speaking, Kerala is a land of migration in India. There is, at least, one migrant worker in each family, who is in abroad. Remittances from migration have significantly contributed to reduce unemployment and poverty in the state. Nurses constitute one of the major sections of the migrant workers in the state. Thus, initially nurses' migration was mainly regionalised in south part of country, especially from Kerala, but of late years, nurses from Punjab are also predominantly migrating to countries such as Canada, Australia, and United States etc.

Impact of migration on nurse migrants
Both positive and negative effect of migration is seen on the individual nurses who migrate abroad. Improved financial status is one of the significant and major effects seen in nurses as high wages is the primary cause of migration that influences the decision of migration. Nurses may earn ten to twenty times more in the destination countries than the home country. With this hike in salary, nurses can improve their lifestyle as well as can send money back to their family and can support their family members. Focusing on the negative impact of migration, the migrant nurses may experience unfavourable circumstances in the destination countries. These nurses may experience challenges like unfamiliar places, staying away from family, trouble adjusting in new environment, difficulty in understanding the foreign language and communication issues, cultural differences, discrimination at workplace and difficulty in adaptation of working standards etc. Sometimes migrant nurses also face challenge in establishing relationships with the colleagues and this ultimately affects their quality of care, patient safety and workplace satisfaction. Maladjustment can also lead to psychological distress and depression among nurses. Moreover, in some countries despite of working for the same hours and same number of shifts, migrant Indian nurses are paid less than the nurses who are born and trained in destination nations 22,23 . One another concern of professional deskilling is constantly seen with migrant nurses. It is seen that Indian nurses, who are preparing or waiting for results of recruitment exams in overseas, may take over lower category nursing jobs. Also in Saudi Arabia, General Nursing and Midwifery Diploma Nurses of India are allowed to work as Assistant Nurses only. Therefore, Government of India, in view of preventing deskilling, has decided that only graduate nurses are permitted to move to Saudi Arabia for employment 21 .

Is migration causing shortages of nurses in India?
The possibility of skilling and sending nurses overseas is immense; there are some drawbacks as well. Despite a high intake capacity annually, India experiences nurses' shortage. Government statistics (2020) reported that India has 1.7nurses for 1,000population, which is way less to World Health Organization prescribed ratio (3nurses/1,000 population) 24 . Due to shortage of nurses in India, there is unequal distribution of nursing manpower between urban and rural areas. Due to this shortage, the years-old discussion on brain drain of nurses has been highlighted and need to motivate nurses to work in own country, especially after COVID-19 has shaken the healthcare system of India. Health administrators showed general equivocation about whether global migration is the vital cause behind shortages of nursing manpower in country. If nurses migrate, it is surely a loss of manpower. However, the statistics are not that threatening. It is noted that remittances obtained are seen to make up for migration and also the training institutes are considered as generating high number of nurses for the purpose of international migration. Therefore, migration of nurses can be viewed as not related to shortages of nurses in aspect of quantity but more about quality, because migration can cause the loss of valuable skills and experienced professionals 24,25 .

Loss of national investment and human capital
Many health bureaucrats believe that migration of Indian nurses to abroad can cause disadvantages to own nation, but always profitable for migrant country, as when professionals move, home nation loses skilled professionals which are trained at cost of the public and the recipient countries gets trained workforce free of cost. Some experts also believe that migration can adversely affect the personal life and family as well, occasionally highlighted aspect of migration, including the elderly parents and children who may stay back and marital issues related to temporary separation and migration 21,22 .

Return migration
Insufficient data related to nurses' migration has averted a precise assessment regarding return migration of nurses. Only very little evidence related to return migration of nurses is available till now. Nurses usually go to abroad for professional advancement and get settle there permanently. Nurses who migrate to countries like US, UK, Canada, and Australia do not usually return back to India and usually migrated with their family. Thus, the chances of return migration from these nations are very less. However, nurses who move to Gulf nations do not settle there permanently and return back after few years of service. However, all returning nurse migrants may experience challenges in re-entering in the main stream. Although returning migrants nurses, can apply for government jobs through advertised recruitment, but age limit is normally 30 years for many central Government institutes. Also, many a time, experience of working in foreign nations may not be acknowledged by professional bodies or employers. Many of nurses coming back from Gulf countries with rich experience but the public sector does not recruit them directly. Private institutes may absorb returnee nurses as such nurses are experienced and corporate institutes require such professionals. Returnee nurses also face challenges related to adaptation in Indian health sector after working abroad. The major challenges include varied practices, different protocol and policies, lack of social and professional networking and different work responsibilities etc. therefore, health bureaucrats must focus on special policies for re-integration of returnee nurses and to encourage medical tourism. Thus, the matter of return migration and re-integration of returnee nurses into practice is essential for consideration 7,21 .

Policies to Regulate Migration of Indian Nurses
In the recent years, Indian government has focused to control and manage the nurses' migration. However, it just seems to be a patchwork of administrative amelioration rather than a centralized policy formulation delineated for nurses' shortage with regulations to greatly facilitate the emigration process of nurses' migration 6,11 .
To limit the migration of nurses, a number of procedural obligations are set for the nurse emigration process. One of such examples includes in some of nursing institutions, there is imposition of employment bonds on passing out students after completion of their degree or diploma in nursing. Also in 2015, Government of India involved nurses in the Emigration Check Required (ECR) category. In Emigration Clearance (EC) system, nurses need to get approval from Protector of Emigrants office, which is located in New Delhi. This policy has channelized nurse recruitment as nurses can only work on international contracts, which are permitted by government authorities. However, emigration clearance process has increased the overall cost of migration. Other than such restriction to limit nurse migration, some more proactive ways to deal with migration is also applied in some states. For instance; in 2018, Kerala Government mandated that nurses working in corporate institutes must get a minimum of Rs 20,000 salary/ month. Such initiate must be taken as a major step to bridge the gap in wages of nurses, which is one of the push factors for international migration of Indian nurses 7,26 .
Comprehensively, various policy amendments may have some effect on nurses' migration. This can be further achieved through administrative refinement, not only by changing to the existing employment process, but also creating sufficient opportunities for the nurses within India for more favourable results. Also, Indian government has considered medical tourism as an economic benefit for the nation. Medical tourism is playing progressive vital role in India; however, it is hard to predict that how this will affect the dynamics of nurses' migration 27 .

Strategies to deal with health care workers migration
Health care workers' migration is not always a choice but many a times, a reflection of losing hope in the home country system to provide them a better future. Wages of nurses should be rational and practical to spend life respectfully. Also work profile should be strictly maintained and academics need to be promoted while working in health care institutes. Time-bound appraisal and fair recruitment in government and private sectors is also necessary. Necessary action like developing infrastructure of the health care system, better technology, patient and health care friendly initiatives is also vital for retaining the nurses within country only. Health care workers are the most respective and prestigious population of any country. The government needs to address its issues on priority.

CONCLUSION
As migration of Indian nurses can be tracked through destination-country data, still a lot is yet to be known about the overall migration pattern. National data about the nurses' migration is exceedingly shattered and therefore it is arduous to know the actual nature and extent of this migratory stream. However, it is definite that amongst aging population and shortage of nurses in developed nations, the movement of Indian nurses will remain continue. There are certain push and pull factors, which are playing vital role for migration of nurses. Challenges related to credential acknowledgement; discrimination at workplace and deskilling are there which migrant nurses are facing internationally. Therefore, bilateral and global involvement is required to solve these challenges. As India is among the top source nation for nurses to the globe, therefore, Indian government can play essential role in monitoring and regulating emigration, which is highly essential as safeguarding the rights of Indian nurses globally.
To sum up, the Indian nurses has enormous opportunity in the international healthcare sector and it should not have to be an either-or situation. Government could go a long way to make strong policies; such as a circular migration policy where nations could allow sharing essential human health workforce and accepting to send migrant nurses back to their country in times of need such as pandemic or country's crisis situations. Evidence of it is already seen during the recent COVID crisis, as Indian health care professionals came back from foreign countries, to serve the motherland and lend a helping hand.