The global care chain and female migration

Healthcare-worker migration represents the longest and best-documented female transnational labour migration [24, 27]. The organized export of female care-workers is documented as early as the 19^th century when the female workforce comprised nuns who travelled to countries of the global south as missionaries and nurses [24, 27]. However, the face of transnational healthcare worker migration has substantially changed in the 21^st century—female migration in the health-sector is now seen in the opposite direction, from the southern to the northern hemisphere and has been described by feminist scholars using the framework of the Global Care Chain (GCC). The Global Care Chain theory analyses international power relations between the global north and south that emanated from a changing transnational organisation of healthcare with a special focus on migrant women from the south and their incorporation in the global healthcare market [24, 27–31]. The term Global Care Chain was first used by the feminist sociologist Arlie Hochschild [32], referring to “a series of links between people across the world based on the paid and unpaid work of caring” (page 131).

The demand for migrant care-workers especially in wealthy industrialized countries is steadily increasing, largely due to an aging population and the failure of states to plan long-term and self-sufficient health-systems [18]. Also, the male-breadwinner stereotype has changed to a more gender equal model of dual-earner in some countries. Although the latter development is positive, it created an imbalance in roles: women have less time available for domestic work once they are part of the labour market, but this is not compensated by an increase in domestic contribution by men [33, 34]. As a result, the domestic care-work is handed over to others, mostly migrant women who work for families on a paid labour basis. Those migrant women then hand their own care responsibilities over to other persons, usually women from their families (elder daughters, mothers or grandmothers) or friends [35].

A lot of research on GCC has focused on migrant women from poorer countries working in private care settings [35, 36]. These female workers often face marginalization, difficult economic situation and unstable legal status in the host country [11, 18, 36]. Smith and Mackintosh [37] and Cuban [36] have exposed this trend in the UK.

However, the handing over of care tasks is not limited to private care. The global care chain exists in the public care sector as well. For a long time, public health-care in industrialized western countries depended on migrant care-workers because the national care workforce was not self-sufficient. Wright and colleagues [9] documented the extraction of care-work from South to North from as early as the 1960s on. Today, South-South migration has increased as well: many African nurses chose to go to upper middle-income countries like South Africa or Botswana [38]. Those countries are also highly dependent on a migrant care-workforce [23]. Also, the United Arab Emirates (UAE), a country whose economy is mostly driven by migrants and known to be recruiting health workers, are a major destination country for migrant nurses [38, 39]. There are studies from the UAE and the Asian Pacific Region that highlight the difficult situation for migrant women in that country, especially for domestic workers [40, 41]. The second field of GCC research, i.e. the public and institutionalized sector of healthcare (e.g. hospitals), focuses on the immigration of high-skilled healthcare workforce and how they fit into a global care economy. Only recently has research on care migration flow focusing on nurses increased [11, 24, 42–47]. A feature often reported by migrant nurses in highly institutional settings is the feeling of devaluation and relatively limited responsibilities compared to their home countries [29, 48]. Even in the more regulated environment of the institutionalized settings with labour rights, migrant nurses often worked in positions they were overqualified for [29]. Another important theme for GCC research is racial discrimination against black female migrant healthcare workers in their work environments [46, 49–51].

In the light of the abovementioned aspects our paper focuses on the migration of high-skilled female nurses and doctors, originating from sub-Saharan African countries, to European (UK, Belgium, Austria) or southern African countries (Botswana, South Africa). There have been few papers drawing on the experiences of foreign trained doctors from the global south migrating to middle- and high-income countries in recent years [52–56]. Female physicians have been entirely neglected in GCC research so far [24]. Moreover, research has mostly focused on Anglo-Saxon countries (as they are the major destination countries for migrating health workers), and barely on health-worker migration to other countries [24, 57]. The aim of our study was to explore the impact of migration on the careers of female migrant health-workers who had been trained in Africa. Furthermore, we wanted to compare the experiences of doctors and nurses and especially study their experiences of deskilling and discrimination.

Design

This study took place as part of a larger EU-funded research project on ‘Human Resources for Primary Healthcare in Africa’ (HURAPRIM) www.huraprim.ugent.be with seven partner countries. Semi-structured interviews with 88 female and male migrant health-workers were conducted in five out of seven project partner countries, namely Botswana, South Africa, the UK, Belgium and Austria between July 2011 and April 2012. In the overall study, the sample was heterogeneous according to gender, country of origin, age, training and time since migration to the destination country. For the purpose of this paper only the interviews with female doctors and female nurses were selected for further analysis (N = 34).

The interviews were conducted using a qualitative semi-structured guide that explored three main research questions: 1) personal experiences and reasons for migration of health-workers, 2) continued links with their countries of origin and 3) future (migration) plans. The interview guide was developed in English and translated into German, Dutch and French; interviews were conducted in the language preferred by the research participant (Dutch (n = 5), French (n = 8), or German (n = 6), English (n = 69)). The Belgian project team member who conducted the interviews also translated the interview guide into Dutch and French and WP checked the translation. The team member from Austria who conducted the interviews translated the guide into German and RK checked the translation. As the interview guide was semi-structured and aimed at framing the topics that needed to be mentioned during the face-to face interview the translation from experienced mother-tongue speakers was considered sufficient for the translation process.

Three of the countries where the interviews were conducted are among the top eight destination countries for migrant health-professionals (Belgium, UK, South Africa) [23]. Austria and Belgium have no history of active recruitment whereas South Africa, UK and Botswana have recruited healthcare workers in the past

Recruitment of participants

The inclusion criteria for the European countries (UK, Belgium, Austria) were: 1) Born in sub-Saharan Africa 2) received professional training in medicine (physicians, nurses or midwifes) in sub-Saharan Africa (one interviewee was not born in sub-Saharan Africa, but had been trained in South Africa). The inclusion criteria for Botswana and South Africa were: 1) Born in another sub-Saharan African country 2) received professional training in medicine (physicians, nurses or midwifes) in another sub-Saharan African country. Participants did not necessarily have to be currently working in a health-related field. They could be working in another field, currently not be working at all, or be students. In the sample analysed for this study (N = 34), five respondents were currently not working in a health related field.

Data collection

In all countries researchers with experience in qualitative research conducted the interviews. The researchers involved in the interviews (conducting, transcribing and analysing) were post-graduate anthropologists and sociologists well-trained in qualitative research methods. Two of three interviewers in the UK for example had attended a qualitative research course (MSc level). Participants were interviewed for 60–90 minutes in English, Dutch, French, or German in a place of their choice, usually work or home. Interviews were recorded and transcribed verbatim by the interviewers themselves or by other team members. Some of the participants in Botswana were telephone-interviewed as it was not possible for the team to arrange a face to face interview because of the distance of their villages from Maun, where the team was based.

Data analysis

The 34 interviews analysed for this paper were imported into the software atlas.ti for qualitative content analysis. One researcher (SW) analysed the interviews and coded them into themes and subthemes [58, 59]. While reading through the interviews a total of 63 codes were defined. For the purpose of this study 27 codes were summarized and analysed under the three overlapping categories “migration and impact on women’s career”, “gendered work dynamics pre and post migration” as well as “experiences of racial discrimination” (see S1 Table). Most of the codes were defined deductively according to themes that emerged from the Global Care Chain literature focusing on high-skilled female health migration (e.g. abroad_racism or abroad_impact professional) and some codes emerged from the interviews using an open inductive coding approach (e.g. abroad_difficulties, personal details). To make the coding scheme and theme development valid and reliable, it was discussed with another researcher familiar with the data material and with extensive knowledge in qualitative methods (RK). The codes were merged into categories and summarized by SW [60]. After several iterations with the co-authors who conducted or were familiar with the content of the interviews the results were finalised.

The results presented below include many original texts/excerpts from the interviews (see also S1, S2, S3 and S4 Texts for original quotes). By doing so, we aim to give the interview partners in the research as strong a voice as possible [61].

Ethics statement

Ethical approval was provided by the ethics committees of each of partners mentioned in the study design section. We here specify in detail ethics committees/approvals related to the five countries included in the study for the paper: Ghent University, Belgium (Ref.: 2011/552), University of Oxford, United Kingdom (MSD/IDREC/C1/2011/96), University of Botswana (PPME 13/18/1 VII (368)), Medical University of Vienna, Austria (EK-Nr: 989/2011), and the University of the Witwatersrand, South Africa (M111122)). The data produced in the project is strictly confidential, and interviewees are anonymous in all transcripts and analyses. To assure anonymity/privacy, names that appear in the results section are all fictitious and we made transparent only the destination country of our respondents. Prior to the interviews, all participants were informed about the HURAPRIM project and its objectives as well as the purpose of the interviews. Written informed consent was obtained from all participants.

The participants were informed about the use of the data for scientific publications.

Migration and impact on women’s careers

Gendered work dynamics pre- and post-migration

Gender themes were sometimes discussed during the interviews without specifically being asked. The stories show a very diverse picture of gendered dynamics (at work) pre- and post-migration:

The decision to leave X was actually two because it was a time, I had just divorced and you know, heartbroken and those years when you were divorced you were regarded as like a low person, low class; a married woman didn't want to associate with you, single women didn't want to associate with you; there was a name that was given to us, a very derogatory name in our language,[…]. and then you just wanted to break away and go away and hide so that these people don't know you are divorced. And then this country was recruiting.

(Irene, nurse, UK)

Irene went to the UK with a recruitment agency, which represents a pull-factor; however, it is important to note that gender stigmatization remained a very important push-factor. In her position as a single, divorced mother of three children she felt isolated and stigmatized in the public as well as the private sphere. Professional career development in her country of origin did not seem to be an option at the moment of migration due to that stigmatization. Only because of the push factors, the pull factors came into play.

In other cases, gender mattered post-migration, particularly in regards to the differences in culture experienced:

At times I find it very difficult to express myself so there's some challenges at work really. The socialising culture is a bit different here than in X. Things like going to the pub, a part of life here; so you have to end up trying to fit into the group and do some of the things which you wouldn't normally have done in X. A pub culture is not [for a] lady, it's there for men, men go to the bar everyday but women don't, it's really different. But I've got used to it now. When I tell my friends in X they can't believe what I'm telling them.

(Grace, physician, UK)

It is really very hard to live in X [first country in Africa she migrated to] as a woman. And I was with my mother and it was hard also to find a job, because they manipulate everything. As a woman without [a] man to live in X is very hard, there is no respect, the community is very complicated.

(Sonia, physician, Austria)

The problems that Sonia mentioned were only raised by her. However, she did mention that feeling of being discriminated as a woman in her job in a former non-European destination country many times during the interview, explaining that it is tough to work as a female (and single) physician surrounded by mostly men. That view is reflected by other studies for example concerning gender-based discrimination of female physicians relating to career advancement possibilities in the US or Japan [68] and in general exclusion of female physicians from power structures of medicine [69] or sexual harassment against women working in the medical field [70].

The point raised by Grace, the physician in the UK, was unique and highlights the different gender cultures one finds when migrating and how to adapt to a new gender culture. Cultural and social constructions of womanhood or manhood differ across countries and regions, therefore a migration also includes being introduced to a new gender culture and having to renegotiate personal gender identities [71, 72].

Experiences of racial discrimination

Many of our respondents reported experiencing discrimination. Some respondents voluntarily shared their experience of not feeling welcome as a foreigner, whereas in other cases this aspect was deduced from the stories themselves. Here are some examples from female doctors:

Some of those issues you have, you can't talk about them in the team, nobody, some people wouldn't know what you're going through as a foreign person working in this country because at times I hear my colleagues say, ‘Why do these foreign doctors come?’ […]

(Grace, physician, UK)

To put this statement into a larger context, it is important to note that respondents with a white European heritage did not mention experiences of discrimination based on being a foreigner which indicates the nature of what Grace talks about—it is not only about being a foreigner, it is about being black. During the interview Grace talked about one particular person that was harassing her; she did not mention any other person correcting this harasser or defending Grace’s case. Racial discrimination against black Africans is also mentioned by respondents in South Africa and Botswana. Beth thought that the university was very welcoming but other parts of social life were not easy for foreign Africans in South Africa. Rita, a physician in Botswana, when asked about what she would change in Botswana, mentioned the behaviour of both co-workers and patients.

From a social sort of environment point of view I think there are issues about—I don’t know about how other Africans from the rest of Africa experience it—but I know my experience resonates with many of my fellow Zambians, Zimbabweans and Kenyans. It’s an ongoing struggle and one just, you sort of get tired of it and think it’s time to go back home. (Beth, physician, South Africa)

The thing is just if they can teach the patients to respect us doctors; doctors and nurses. We know we are foreigners, but we are giving good service here if they could just respect us I will be happy to work here in Botswana, even to stay here forever.

(Rita, physician, Botswana)

Nurses had similar experiences and feelings of being discriminated against. The different narrations show a variety of features of racial discrimination. The narration from Irene illustrates how racist behaviour is to be found in the public sphere in general as well as in the work place. No environment is safe from it. It can come as an attitude from co-workers (see quote Marian), consultants (see quote Catherine) or from a random person at the airport (Irene).

By the time I left X I was a senior nurse so you come to a new country whereby, first of all, people really treated you as an underdog. I don't like to say but it was the effect that because of your colour; because you came from Africa, the third world. Somebody would ask me, ‘Oh where did you buy your clothes, did you buy them at the airport? Do you wear clothes in X; I thought you wear, you know, those kinds of things. (Irene, nurse, UK)

Hatred between co-worker and co-worker more especially when it comes to foreigners. Foreigners, we are not loved in Botswana. […] you find someone is asking ‘Ah! You! […] you are eating our money!’

(Marian, nurse, Botswana)

And the consultant back then, I remember the words she used were so offensive: ‘You do not have to repeat nutrition classes, because after all you lived in [another European country] for 17 years.’ As if we in X wouldn’t know what vitamins are or what nutrition means. Those are people that simply have no idea, they only look at the paper […]. Really, a horse can see more; those people wear those blinkers and don’t see what is going on beyond them.

(Catherine, nurse, Austria)

A similar experience at the workplace shared by Uma was reported in a study from Aboderin [62]. The author mentions interview reports from struggles over authority between white carers and black Nigerian nurses in the UK.

Working in the ward with somebody who'll tell you that, ‘Oh you are a registered nurse? No but I'd been a carer in this ward for more than ten years so don’t come with an attitude of thinking you're going to run this ward. I'm in charge here.’ There's an exchange of roles because I'm a nurse and I qualified in X, together with the fact that I'm black, I cannot work as a registered nurse with the healthcare-assistant who's been there for ten years. […] “

(Uma, nurse, UK)

Racial discrimination makes the struggle for integration, creating a positive social environment, finding a job and feeling at home even more difficult than it already is for transnational migrants, as the account of Beth shows: “it is an on-going struggle and you get tired of it” (Beth, physician, South Africa).

A major problem in all the stories seems to be that there is no strong public condemnation of racial discrimination at the work place. An anti-racist consensus in the work places is obviously missing. However, Uma underlines in her interview that the situation was worse when she arrived many years ago in the UK where she had no institutional or political support to condemn racism at the work place, which indicates that some change happens at least at institutional level.