International medical migration: what is the future for Australia?

From the 2005–06 financial year to 2010–11, 17 910 IMGs were sponsored to Australia on a temporary basis, with a further 2790 selected as permanent skilled migrants.1,2 Thousands of additional IMGs arrived unfiltered in advance for human capital attributes, admitted as spouses and through Australia’s family or humanitarian categories. Recent IMGs have trained in highly diverse countries, associated with very variable English language testing results and medical registration and employment outcomes.

Despite such challenges, I argue that Australia’s reliance on IMGs is likely to be maintained in the future, owing to a combination of factors. First, medical migration remains Australia’s key strategy for addressing medical workforce maldistribution, with competition to recruit and retain medical migrants recently intensifying rather than diminishing. Second, the Competent Authority Pathway for registration has improved IMGs’ outcomes, enhancing their immediate value as a source of supply. Third, Australia has become increasingly reliant on internationally trained specialists to serve in select undersupplied fields. Fourth, there is growing Australian demand for international medical students, who achieve exceptional early outcomes relative to IMGs. Despite greatly enhanced investment in domestic student training, Australia’s dependence on international migration thus appears likely to persist rather than reduce in the foreseeable future.

By 2006, 45% of medically qualified residents were overseas-born, including an estimated 25% who were overseas-qualified.3 In 2001–2006, 7596 doctors migrated to Australia across all immigration categories — double the number admitted from 1996 to 2000. India, the United Kingdom/Ireland, Sri Lanka/Bangladesh, China, other southern and central Asian countries, North Africa/the Middle East, South Africa, sub-Saharan Africa (excluding South Africa), and the Philippines were the primary source countries at this time (Box 1).4

Medical workforce diversification has proven challenging, however. Just 53% of IMGs who arrived in Australia during 2001–2006 secured medical employment by 2006 (across all immigration categories). Doctors from English-speaking countries made the transition seamlessly, while Asian-Commonwealth doctors from countries such as Singapore and Malaysia, India, Sri Lanka and Bangladesh fared reasonably well. Outcomes were poor for many other birthplace groups (Box 1). Just 6% from China had found medical employment within 5 years, 23% from Vietnam and 31% from Eastern Europe. Many had arrived through the family and humanitarian categories — untested in advance for employment attributes or registerability.4 Thousands were also admitted as spouses. Large numbers of recently arrived IMGs were defined as “not in the labour force” — a proxy for learning English and/or trying to pass preregistration exams. English testing for example was a powerful barrier. By 2010, a pass rate of only 43% was the Occupational English Test norm for medical applicants, rising to 52% in 2011.1

Despite highly diverse source countries, workforce integration is best for IMGs selected through Australia’s 457 visa temporary sponsored pathway (99% employed at 6 months), followed by those entering under the permanent General Skilled Migration Program. These flows now dominate (Box 2). This pathway is highly attractive to governments and employers given the potential to prescribe IMGs’ location as a condition of visa entry, allowing them to work for up to 4 years at undersupplied sites.

By 2009, 70% of labour migrants were sponsored, reflecting the recent dramatic privatisation of Australia’s skilled migration program. From 2005–06 to 2009–10, 34 870 health professionals were selected as temporary 457 visa migrants. Nurses (46%) and doctors (44%) dominated. A further 2420 visas were awarded to temporary IMGs in 2010–11: 1190 for general medical practitioners and 1230 for resident (house) medical officers (mostly new appointments). In 2010–11, most such IMGs were recruited to Victoria (600), New South Wales (540), Queensland (500) and Western Australia (280).2 From 2004–05 to 2009–10 an additional 15 940 General Skilled Migration category migrants holding health qualifications were admitted permanently, primarily qualified in nursing (52%), medicine (15%) and pharmacy (13%). In 2010–11, 460 more IMGs were approved.1,2

Additional doctors arrive from New Zealand — enjoying free entry rights under the Trans-Tasman Mutual Recognition Arrangement, in a context where 12% of the New Zealand population is currently resident in Australia. By 2006, 1163 New Zealand physicians were based in Australia, including 240 admitted from 2001 to 2006.1

New Zealand doctors face no employment barriers in Australia. Analysis of 28 years of Australian Medical Council (AMC) data, however, reveals that other IMGs experience highly variable registration outcomes. The most detailed study to date, commissioned by the Department of Health and Ageing, showed that just a third of recently arrived IMGs had attempted to pass the AMC preaccreditation exams in the years preceding 2007. Of those IMGs attempting it, 78% were medically employed within 5 years, despite just 41% having by then secured unconditional registration.5

According to the AMC Submission to the House of Representatives Standing Committee on Health and Ageing Inquiry into Registration Processes and Support for Overseas Trained Doctors (2011) and additional data provided to me, from 2004–10, 57% of IMGs aged 21–30 years passed the multiple choice question examination on their first attempt, compared with 46% aged 41–50 years and 31% aged over 50. Similar trends were evident in the clinical examination.6 Box 3 reports outcomes by the top 10 countries of training.

In 2008, given mounting concern, the Australian Government initiated “a national assessment process for overseas qualified doctors to ensure appropriate standards in qualifications and training as well as increase the efficiency of the assessment process”.7 Multiple pathways to practice have since developed, including the fast-track “Competent Authority” option for doctors registered in New Zealand, the UK, Ireland, the United States and Canada. Eligible source countries may opt out — Singapore and South Africa have done so to minimise workforce loss.6 For IMGs requiring greater periods of adjustment, alternative pathways have been designed to provide enhanced supervision, address differential levels of training need, and increase readiness for specific locations of practice.

To redress medical workforce undersupply, Health Workforce Australia has been charged by the Australian Health Ministers’ Conference with developing a national training plan. The goal is to reach self-sufficiency by 2025.

In the foreseeable future, however, medical migration seems certain to remain an imperative for Australia, given Australia’s ageing patient and practitioner base, reduced hours worked by younger cohorts, the growing feminisation of medicine, limited access to internship places, and distribution challenges. The Department of Immigration and Citizenship has recently set “occupation ceilings” for skilled migration in 2012–13. In medicine, the ceiling is 4860 people, compared with 15 660 in nursing, 1380 in pharmacy and 720 in dentistry (numbers are reported at http://www.immi.gov.au/skills/skillselect).

Between 2004 and 2009, the number of Australian domestic medical completions rose from 1287 to 1915. Provisional registrations rose from 1699 to 2955.25 Incentive schemes were also developed (most notably the Bonded Medical Places Scheme, to which 25% of all first-year Commonwealth supported medical school places are allocated) to encourage medical graduates to serve in areas with an undersupply of doctors. Despite such measures, dependence on IMGs seems certain to remain strong, as confirmed by the recent House of Representatives inquiry into overseas-trained doctors.15 Australia is not alone in this reliance, which is intensifying across OECD nations.26-29 The challenge will be positioning to recruit and retain “the best” medical migrants, in the context of the highly variable registration and employment outcomes that many initially achieve. To facilitate this, collective action by all relevant jurisdictions will be essential.