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Aspects macro-économiques de la migration : conséquences sur le secteur de la santé et les inégalités

Tajik healthcare workers on the move: causes, consequences and responses

Professionnels de la santé tadjiks en migration : causes, conséquences et réponses
Таджикские медицинские работники в движении: причины, последствия и ответы
Ilhom Bandaev, Rukhshona Kurbonova et Marya Samuilova
p. 305-330

Résumés

En 2012-2013, avec l’appui du Fonds de développement de l’oim et en collaboration avec le Ministère de la santé et de la protection sociale de la République du Tadjikistan, l’oim a mené une étude sur les causes, les conséquences et les réponses à la migration des agents de santé tadjiks. Avant cette étude, la question de la mobilité des professionnels de santé tadjiks à l’étranger était très peu considérée. Les résultats de la recherche présentés ici comblent cet écart en mettant l’accent sur les facteurs de répulsion et d’attraction qui affectent la mobilité des professionnels de santé du Tadjikistan. Cette enquête analyse le lien entre la migration des agents de santé et la capacité du système de santé au Tadjikistan à gérer ce phénomène, et la réponse politique nationale à cet égard. Cette étude est basée sur des approches qualitatives et quantitatives. Les résultats indiquent que le manque de ressources financières au sein du système de santé tadjik, les bas salaires, en particulier dans les zones rurales peu attractives, et les opportunités limitées de développement professionnel, sont les principaux facteurs de migration des professionnels de santé tadjiks. Une rémunération plus élevée, de meilleures conditions de travail et le développement professionnel sont les principaux facteurs d’attraction des professionnels de la santé dans les pays d’accueil, le principal pays de destination étant la Fédération de Russie. Le développement du secteur privé de santé peut réduire l’émigration des professionnels de santé. Le Ministère de la Santé et de la Protection sociale tadjik peut retenir les professionnels de santé en étendant les soins médicaux privés, en fournissant des incitations aux travailleurs médicaux – en particulier dans les zones rurales – et en mettant en œuvre un nouveau mécanisme de paiement aux prestataires de soins par habitant au premier échelon du système de soins.

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Introduction

1Although during Soviet times health professionals served in Afghanistan, Yemen, Mongolia and other countries, the nature of the employment abroad had mainly political purpose. According to research done concerning these periods of the country history, health professionals were recruited by the relevant state agencies including security services to play the role of “soft power”: demonstrating disinterestedness, internationalism, and in the same time promoting the capacity of the Soviet medicine and the achievements of the socialist system (Baškiev, 2012; Ben Lamlas, 2002).

  • 1 Agency for Statistics under the President of the Republic of Tajikistan. Statistic of the labour mi (...)
  • 2 Agency for Statistics under the President of the Republic of Tajikistan. Statistic of the labour mi (...)
  • 3 Interview with Mihail Murashko – head of the Roszdravnadzor. Rossiyskaya Gazeta, Federalniy Vypusk. (...)

2Since the collapse of the Soviet Union in 1991, the Republic of Tajikistan became actively involved in labour migration processes. The civil war and the decades of the underinvestment affected negatively the Tajik health system and reflected in out-migration of many doctors and nurses abroad (Khodjamurodov, Rechel, 2010; Tajik Ministry of Health and Social Protection 2010). In the last 10 years, the Republic of Tajikistan became one of the most remittances dependent country in the world: only in 2013 remittances were equal to 50% of the national gdp (World Bank 2014, Rubinov, 2016). According to official data, 799 700 Tajik citizens left the country to seek for better economic opportunities in 2013 which is twice higher than in 20051. Almost 97,8 per cent migrated to the Russian Federation and about 1,0 per cent left for other Commonwealth of Independent States (cis) countries2. The Russian Federation attracts Tajik migrants with steady workforce demand, high wages, absence of visa regime, relatively low travel expenses and familiarity with the local language and culture. The Russian health authorities reported that the number of foreign health professionals applying for job in Russia in the last five years increased twice3.

3According to who the number of health workers per capita in Tajikistan has declined after 1990 for all professional categories. For example, the number of midwives felt from 129 per 100 000 in 1990 to 54 per 100 000 in 2013. The Centers for Disease Control and Prevention (cdc) noted a lack of 67 medical staff in the Tajik State Sanitary Epidemiological Surveillance Services (who, 2013). The number of physicians declined from 255 in 1990 to 170 in 2013 per 100 000 population. The latest report on the country health care system suggests that the Republic of Tajikistan has less health workers per 100 000 than in Western Europe, most of the former Soviet Union countries and other countries of the Central Asia region (Khodjamurodov, Sodiqova, Akkazieva, Rechel, 2016; Tajik Ministry of Health and Social Protection, 2010).

  • 4 who. Regional Office for Europe. Evaluation of the Structure and Provision of Primary Care in Tajik (...)

4The shortage of health professionals is complicated by the lack of enough medical graduates of the Tajik State Medical University which cannot cover the needs of the country due to the population growth and healthcare reforms (Jabarova, Muhiddinov, 2016; Tajik Ministry of Health and Social Protection 2010, p. 50). In addition, who notes the regional imbalance of health providers in Tajikistan4. while three quarters of the country’s 8,4 million people live in rural areas, the lowest concentration of human resources is observed in the remote areas of Khatlon region and the Districts of Republican Subordination (Khodjamurodov, Sodiqova, Akkazieva & Rechel, 2016; Tajik Ministry of Health and Social Protection, 2010, p. 49).

  • 5 Ibid.

5This shortage of health professionals impacts on the health outcomes in Tajikistan. For example, the difficult access to healthcare in the rural areas caused 20% of the births not to be attended by a health care professional in 2009. A comparison with the neighboring former Soviet republics suggests that the situation in Tajikistan is worst (as regards countries where data are available); in Kazakhstan, Kyrgyzstan and Russia all births are attended by a health care professional. Despite the constant reduction in infant mortality rates in Tajikistan, the rate alone, however, remains rather high. A comparison with other countries confirms this trend: Tajikistan is placed in the middle of the world infant mortality ranking5. Low tb detection rate (Aye, Wyss, Abdualimova, Saidaliev, 2010), tb treatment interruption due to missed tb treatment adherence support during out-patient tb treatment is another example of the consequences of the limited presence of health providers at primary health care level (usaid tb Control Program, 2015).

6In this context, the Ministry of Health and Social Protection of the Republic of Tajikistan raised the problem of the lack of information on the extent, reasons behind and effect of the migration of health professionals in order to better understand this process and develop solutions to deal with it. iom Tajikistan jointly with the Ministry of Health and Social Protection of the Republic of Tajikistan, and with the financial support of iom Development Fund conducted a study on the causes, consequences and response to migration of Tajik workers abroad exploring the following key elements: push and pull factors, links between migration of health workers and the capacity of the healthcare system in Tajikistan, and developed recommendations of how best to address the migration of this group of highly skilled professionals. The research also contributed to the implementation of who Global Code of Practice on the International Recruitment of Health Personnel by building a knowledge bank on migration of the Tajik health professionals that help government develop evidence based solution for the better management of the workforce planning in the country. According to the adopted Code and recommendations on how to reach the goal of the Universal Health Coverage (uhc), governments have to provide sound health workforce planning, conditions for professional development, promote innovative approaches for service delivery and regulation (who, 2014).

Methodology

7In order to provide a though assessment of the situation, a combination of quantitative and qualitative methodologies were applied.

81. Face to face interviews: Face-to-face interviews were held with 301 health professionals: 222 were doctors and 79 nurses. The sampling was conducted in two steps. Initially the Tajik Ministry of Health and Social Protection suggested the specialties of the health workers that are more prone to migration. Identified specialties were distributed by regions. It was decided that nurses will be interviewed in the same health facilities where doctors were questioned. In the second stage a convenient sampling was applied for the choice of locations for interviews with physicians and nurses. Separate questionnaires were developed for each group, partially overlapping on certain topics.

  • 6 Having a population of more than 50,000 people (Dushanbe not included): Hudjand, Kulyab, Kurgan-tub (...)
  • 7 Having a population of less than 50,000 people.

9The complete sample is divided in four groups depending on the type of settlement wherein respondents work and live. The first one includes the capital city Dushanbe (about 30% of the respondents), the second one – cities6 (approximately 10%), the third one – towns7 (about 15%), and the fourth one – rural areas (approximately 45%). Thus the survey was conducted in the capital of Tajikistan – Dushanbe, as well as in the districts of the Republica (Subordination, Gorno-Badakhshan, Sogd and Khatlon Oblasts). This enabled us to study the possible influence on emigration inclinations on the axis urban center – non-urban periphery. In terms of medical specialty, the percentage of general practitioners and therapists was the highest (each constituted approximately 20% of the respondents) (Fig. 1). Dentists, surgeons and obstetricians constituted about 12-15% each, and traumatologists, urologists, cardiologists and anesthesiologists – 5% each group. Oncologists were the smallest group – about 1% of all interviewed doctors.

Figure 1
Doctors’ specialty (N=222)

Figure 1Doctors’ specialty (N=222)

102. In-depth interviews: 16 in-depth interviews were conducted with representatives of state institutions, nongovernmental organizations, practicing doctors who plan to migrate and/or have returned home after working abroad. Several guides were developed for the in-depth interviews: a guide for the state authorities, a guide for non governmental organizations, a guide for potential migrants, and a guide for returned health workers.

113. Focus groups: Two focus group discussions with 18 participants were organized among students and post graduates of the Tajik State Medical University. The discussions were recorded. The recordings were transcribed and used as raw material for further analysis.

Limitations

12The main limitation was the absence of a central database of health facilities in the Ministry of Health and Social Protection of rt that makes impossible random sampling of the health facilities. In some health facilities, the doctors of the suggested by the Ministry of Health and Social Protection of rt specialties did not exist in the staff list and interviews were conducted with the physician on duty.

13Present article discussed the perceptions of the health system of Tajikistan, attitudes toward migration, push, pull and restraining factors, expectations and concerns as well as recommendations to address the brain drain challenge faced by the Tajik Ministry of Health and Social Protection.

Results

Perception of the health system of Tajikistan

14Starting from the fact that the working environment is a major enhancing factor in the individuals’ perception of migration, one of the major blocks of questions included in the study referred to respondent’s perception of the health care system. Thus interviewees were asked to assess the positive and negative aspects of their daily work atmosphere. Both groups of doctors and nurses share similar opinions as to the advantages and disadvantages they face. Excellent professional training and high quality education, which allows them to acquire and improve their qualifications, are pointed as the major advantages of the health care system. Approximately 20% of the respondents regard employment opportunities and respective higher remuneration offered by local private clinics as a positive aspect of the health care system; approximately 15% cite existing vacancies, which facilitate their job search, as an advantage. Some nurses (approximately 20%) mention the availability of medical and other equipment in health care units as an advantage. This opinion is, however, shared only by 5% of the doctors.

15The two groups of professionals share the same viewpoint on the disadvantages and problems they face in respect to the health care system. Their criticism is directed at three negative aspects: low remuneration levels as the first major challenge and a weak point of the health care system; insufficient medical equipment and thirdly the shortage of medical personnel. As regards existing problems, again the most commented ones are related to funding and remuneration, and afterwards to issues related to the outdated and insufficient equipment in health care facilities and the shortage of medical personnel, especially in rural areas. As such the perception of the health care system affects clearly the attitudes of interviewees towards migration.

Attitudes towards migration

16Approximately 60% of the respondents are likely to consider the opportunity to work abroad in the same professional field while only one-fifth of the respondents do not approve employment abroad. The positive attitude among doctors is nearly twice higher than among nurses. Approximately 40% of the nurses do not have a definite opinion about working abroad (Fig 2). There is a lower probability of emigration in their group as compared with that of doctors. The research findings reveal several other social and demographic features relating to the approval of labor migration, which create more favorable conditions for turning an abstract attitude into migration behavior.

Figure 2
Attitude towards the opportunity to work abroad in the same professional field

Figure 2Attitude towards the opportunity to work abroad in the same professional field
  • 8 With respect to the high rates in Gorno-Badakhshan (gbao), we should mention again and take into co (...)

17First, medical professionals working in the capital city and larger cities are more liable to contemplate the idea of pursuing a medical career abroad than those who work in rural areas.8 Men approve migration more often than women. More often women are not interested in this topic and do not have a definite opinion thereon. Married respondents are more favorably disposed to the idea of labor migration as compared with those who are single. Married respondents fall into the category of potential labor migrants twice as often as single ones: approximately 30% of married respondents have undertaken actions to start work abroad whereas among single respondents this percentage is approximately 15%. The results of different age groups do not vary as regards their attitude towards working abroad: the percentage of those approving a career abroad is very similar among younger and older respondents.

18In contrast to the attitude and abstract approval, when we analyze the behavior and particular actions in seeking and finding employment abroad, it appears that the proportion of potential labor migrants decreases by half. Approximately 25% of the respondents have taken actual steps in finding a new job abroad: they have sought information, looked for and got in touch with potential employers, contacted employment agencies, etc. In this respect, there are not significant differences between doctors and nurses: about a quarter of the respondents from both groups have undertaken actions to find employment abroad.

19The trend for medical professionals living in the capital city to be more active than their colleagues living in the countryside is preserved. About 40% of the respondents working in Dushanbe and as many as half of the respondents from the group of those working in the countryside can be classified in the category of potential migrants (Fig 3). The research suggests that medical professionals aged 30-50 more frequently take steps in this direction, followed by their youngest colleagues. In older age groups, real actions resulting in labor migration are rarely undertaken.

20According to the research results, jobs are usually found through colleagues and friends working abroad (or having already worked abroad), who are acquainted with the situation and procedures in the respective country and have established contacts with employers. Half of those trying to leave Tajikistan proceed likewise. Approximately 20-25% of the respondents have used employment agency services (35-40% of the nurses).

21The idea of employment abroad in a field different from medicine is not so strongly supported. This option is accepted by 30% of the respondents (in comparison, 60% of the respondents are inclined to work abroad in the field of medicine). If the observed trend is followed (namely, half of those generally approving migration take steps in this direction), we may assume that only 10% of all interviewed medical professionals are inclined to work abroad in another field. Fewer respondents actually emigrate and change their profession. This finding is supported by the declared intentions of potential migrants. Approximately 90% of them claim that they prepare to work in their specialty or another medical specialty. Nurses declare three times more frequently than doctors that before going abroad they prepare for employment in another medical field. Respondents who are willing to work in a completely different field of public services are rather an exception.

Figure 3
Attitude towards the opportunity to work abroad in the same professional field, by region

Figure 3Attitude towards the opportunity to work abroad in the same professional field, by region

22Among the respondents who are classified into the category of potential labor migrants, there are very few medical professionals who would agree to take a job without signing a contract, i.e. to be employed in the black labor market. The qualitative research findings confirm the data related to the professional orientation of doctors searching for jobs outside Tajikistan. They claim that they fall into a special category of labor migrants: most will not leave the country to seek any employment but will emigrate only after they have already found similar work to their work in Tajikistan. They basically make preparations in advance in order to guarantee their career development and high income.

23A migration inclination (approval of employment abroad) does not always result in migration behavior (actions to find a job abroad). Likewise, migration behavior does not always transform a migration option into real migration. Although 30% of all interviewed doctors may be regarded as potential labor migrants, only 5-6% of them actually have migration experience and intend to leave the country within one-year period.

Destinations

24Approximately 80% of the interviewed medical professionals who are potential migrants indicate Russia as the destination country where they would seek employment. This percentage among nurses is even higher – approximately 95%. The other indicated countries (usa, Germany, Iran) should be viewed only as desired destinations since they have low potential for actual migration. Arab countries are the second preferred destination – approximately 25% of the respondents choose them. They are, however, pointed out only by doctors (about 30%). Not a single nurse chose them as a potential destination. Only Yemen is probably an exception: in the quantitative research, it is rarely mentioned as a destination country, but in the qualitative research, it is frequently cited as a destination country as well as a place where many Tajik physicians are employed. Afghanistan was indicated as a destination country based on the experience of some Tajik doctors to work there being recruited by the humanitarian international organizations.

25Several reasons affect the choice of the Russian Federation as a destination country, preferred not only by Tajiks but also by citizens of other Commonwealth Independent States (cis) countries in the region:

  1. Common historical past;

  2. Lack of language barrier;

  3. Knowledge of the Russian cultural environment and lifestyle;

  4. Relatively rapid and easy integration of migrants into the Russian ethno-cultural environment (Èrgešbaev, 2009);

  5. Common system of medical education which still uses Russian language as the main teaching language and utilizes most medical resources in Russian language;

  6. Familiar healthcare system based on Soviet Semashko model (Sheiman, 2013)

  7. Higher salary (Fig 4)

  • 9 Migracionnaâ situaciâ v Rossijskoj Federacii i khod realizacii dokumentov, prinâtykh v ramkakh Sodr (...)

26Furthermore, the Russian Federation has a large number of vacancies resulting in increased labor force demand. In 2011 the shortage of doctors from clinical specialties in the Russian Federation was 152 806 places, and the ratio doctor/nurse was 1:2,1 while the norm is 1:3 (Kuznecov, Kalinin, Trusova, Rasskazova, 2014). Although the Russian migration policy is considered inconsistent, contradictory and ineffective, it succeeds in attracting labor migrants from Central Asian Republics: only in 2011 this group of labor migrants constituted a more than one-third of foreign laborers in Russia9.

27As already mentioned hereinabove, the qualitative research findings confirm and supplement the quantitative data. Russia and Arab countries, especially Yemen, are cited as preferred destinations for employment as well as the countries where Tajik medical professionals most frequently migrate.

  • 10 National Bank of Tajikistan – Statistics, Real sector, Wages (http://www.stat.tj/en/library/wages.x (...)

Figure 4
Average salaries, Tajikistan and Russia, 2010 (in
usd)10

Figure 4Average salaries, Tajikistan and Russia, 2010 (in usd)10

Push, pull factors and restraining factors

28The research employs a set of questions, similar in content, to examine the factors causing and sustaining the labor migration of medical professionals. Regardless of questions formulation, as already explained, the low remuneration is identified as a primary motivation for labor migration (Fig 5 and Fig 6)

Figure 5
Monthly salaries in
usd

Figure 5Monthly salaries in usd

Figure 6
Is your monthly salary enough to cover your needs?

Figure 6Is your monthly salary enough to cover your needs?

29The health care system in Tajikistan is largely state owned being shaped in the Soviet period. The majority of the health facilities are under the administration of the Tajik Ministry of Health and Social Protection. The private sector started to grow only recently and still remains small (1,6%). The mandatory health insurance is under discussion and was postponed several times. Voluntary health insurance does not exist. Funding for health expenditures comes from three sources: out of pocket payments (59,1%), the state budget (30,6%) and international development assistance (10,3%). The vast majority of the funds comes from regional and/or local authorities: in 2012 it accounted to 81,2%.

  • 11 World Bank – data, indicators, healthcare (http://data.worldbank.org/indicator/SH.XPD.totL.ZS)

Figure 7
Expenditures for healthcare. Countries of the Central Asia and Russian Federation, 2010
11

Figure 7Expenditures for healthcare. Countries of the Central Asia and Russian Federation, 201011

30The total health expenditures in 2013 amounted to 6,8% of gdp. According to who (2013), Tajikistan has the lowest total health expenditures per capita in the who European Region, which is 170 usd (purchasing power parity), while the proportion of the out of pocket (oop) payments reached 60% and is one of the highest in the who European Region (average was 26,4%). The Government expenditures on health is 30,6% of the total health expenditures in 2013. According to World Bank the Republic of Tajikistan has the lowest rate of the expenditures for healthcare among Central Asian countries and Russian Federation (Fig 7).

  • 12 Ministry of Health and Social Protection of rt. Joint Annual Review. National Health Strategy for 2 (...)

31In an effort to limit the out of pocket payments, the Ministry of Health and Social Protection of rt developed and approved a Basic Benefit Package (bbp) in 2004 that guarantee a pre-determined list of medical services provided free of charge through the state budget. Unfortunately, the Ministry of Finance and local authorities did not allocate enough funds to cover the bbp deficit that arose, the idea was implemented partially. Nonetheless, in 2014, the patient’s co-payments under the bbp made up over 11 million Tajik somoni in the 14 pilot districts that were spent for purchasing medicines and paying the salaries of the health providers (25,2%)12.

32Although the salaries of health workers is the largest expenditure item in the public health budget (83,1% in 2013), the level of wages is still low. In 2012, the salaries were increased with 40%, however the monthly salary of the family doctors still amounted to 513 somoni which is below the subsistence level of 536 somoni (112 usd in 2012 and 60,9 usd in 2017 due to increased cost of the us dollars) (Khodjamurodov, Sodiqova, Akkazieva, Rechel, 2016).

33In the same time, different studies demonstrate that richer quintiles of the populations utilize three times more often health services than poorer quintiles (Khodjamurodov, Sodiqova, Akkazieva, Rechel, 2016, p. 98). The number of people who reported informal payments is high as well; it has increased from 33% in 2006 to 39% in 2010. The amount of informal payments increased from 5,3 usd in 2005 to 10,7 usd in 2011. At the same time, the biggest share of informal payments is spent for medicines (Khodjamurodov, Sodiqova, Akkazieva, Rechel, 2016, p. 55). Taking into account the poverty level in Tajikistan, it is clear that the out of pocket payments cannot significantly increase the income of the health providers and particularly in rural areas.

34This situation causes dissatisfaction among doctors and nurses, fosters migration inclinations, energizes migration behavior, and finally, urges some of them to emigrate. About two-thirds of potential migrants cite higher remuneration opportunities abroad as a motivation of potential migrants to seek employment in foreign labor markets.

35The new reform of the health financing piloted by the Tajik Ministry of Health and Social Protection rolling out per capita payment in primary health care and case-based payment at hospital level is expected to address the issue of low salaries of medical workers.

36In terms of pull factors, half of the respondents think that various circumstances related to career development and improvement of professional qualifications represent such a factor (a factor attracting healthcare workers to a new location): new technologies, highly qualified teams, and innovative treatment methods. The replies of doctors and nurses do not differ substantially.

37In terms of restraining factors, namely to retain medical professionals in Tajikistan and limit labor migration, family circumstances rank first. Approximately 60% of potential migrants cite them as a major factor retaining them in the country or stimulating them to return after short-term employment abroad. Financial problems and inability of medical professionals to cover their expenses at the initial stage of the migration process (those relating to employment agency services, preparation of documents, travel costs, accommodation, etc.) are placed second. According to approximately 15% of all respondents, the lack of information discourages the labor migration of medical professionals.

38Only about 10% of the interviewees consider that a language barrier may limit labor migration. Such low result is not surprising since Russia is the main destination country. The research findings do not reveal any important factors, concerning work environment, which may stimulate medical professionals to stay in Tajikistan (except for the financial problems discussed hereinabove). In the work place, respondents’ relations with their colleagues and flexible working hours are most highly valued. Neither of them, however, may retain potential migrants among the medical professions in Tajikistan. The qualitative research findings also focus on the family connections as a factor preventing migration (Fig 8).

Figure 8
Retention factors of the migration of the health professionals

Figure 8Retention factors of the migration of the health professionals

Expectations and concerns

39The expectations about labor migration are generally positive: the respondents consider that in most cases it improves the living standard and, more importantly, the financial situation of the health workers – the latter being their primary aim. Simultaneously, the substitution of the familiar social environment for a new, more or less unfamiliar one in a foreign country causes uneasiness and anxiety. They are frequently related to securing of employment. Approximately 50-55% of the interviewed potential migrants express such apprehensions – either about finding employment in the field of medicine or finding any job at all. Concerns about expenses – initial as well as living expenses – are placed second. Approximately 35% of the respondents cite daily living expenses as a cause of their apprehension. Nurses feel such an anxiety more often than doctors about 60% of them and about 30% of the doctors. The difference in the remuneration levels in both groups may be the reason for this difference of opinion: in all countries, nurses receive lower salaries than doctors. Approximately 15% of the interviewed potential migrants are concerned about their eligibility for residence and work permits. Approximately 10% of potential migrants feel insecure about changes in their work environment and subsequent adaptation to the requirements of a new employer and new working conditions. These fears are three times more common among doctors (about 15%) than among nurses (about 5%). This is due to the nature of their work: nurses perform routine activities whereas doctors (especially in some fields of medicine) have to make decisions affecting patients’ lives. Therefore, nurses adapt to new working conditions more easily than doctors.

40Many doctors seeking employment abroad are convinced that they will not be offered much better working conditions in foreign countries as compared to those in Tajikistan. Approximately three-quarters of the doctors and two-thirds of the nurses support this assumption. The interviewed medical professionals from Dushanbe state more frequently than others that their employment abroad will not result in an improvement in their working conditions: approximately 30% of them think that the working conditions abroad will be the same as those in their current work place. In comparison, approximately 10% of the respondents working in small settlements share this viewpoint. This difference probably originates from the contrast between capacity of the health care facilities located in the capital city and those in other areas of the country: health care facilities in Dushanbe have better equipment and more closely resemble hospitals abroad.

41Doctors’ expectations about the remuneration levels abroad are an interesting issue. On the one hand, their replies indirectly reflect their demands for higher pay in Tajikistan. On the other hand, the difference between their current remuneration and the one they expect to receive abroad enables to define to what extent they are attracted to foreign labor markets. The majority of them (approximately 45%) anticipate that they will be paid between usd 1,000 and 2,000 per month. Approximately 30% of them hope for a monthly salary of usd 2,000-3,000. The average salary expected by about 70% of the interviewed doctors, potential migrants, is about 10 times higher than the maximum salary received by 85% of all interviewed doctors in this study (usd 250). As already noted hereinabove, the average salary in the health care system in the main destination country (Russia) is also approximately 10 times higher than the average salary in the same sector in Tajikistan. The Tajik economy is obviously not capable of reconciling these differences. Therefore, the migration rates among medical professionals will remain high.

42Many respondents expect that the situation of migrants shall improve with respect to several aspects. First, the living standard of other family members and relatives, still residing in Tajikistan, shall rise due to the remittances sent by the migrants. According to approximately 70% of the respondents, the income of migrants’ families in Tajikistan increases because they receive money from their members working abroad. Approximately 70% of the respondents think that the living conditions of migrants’ families improve as a result of their higher income. Approximately 50% of the respondents state that migrants frequently help their families, residing in Tajikistan, by buying household appliances. The second source of benefits migrant involves their personal income. Approximately 60% of the respondents express the opinion that the majority of labor migrants receive a regular and steady income abroad. About three-quarters of the respondents suppose that medical professionals earn a higher income abroad as compared to their previous remuneration in Tajikistan. The third aspect, as regards the improvement of migrants’ situation, relates to working and living conditions. Approximately 70% of the respondents believe that the conditions in which migrants work (modern equipment, human resource management, etc.) are better than those in Tajikistan. Approximately 60% of the respondents assume that labor migrants enjoy better living conditions as well. The fourth aspect concerns the effect of migration on the personal development of medical professionals. However, the respondents are not so certain about its beneficial influence. Approximately 45% of the respondents think that migrants acquire higher social status abroad than they had in Tajikistan. Approximately 45% of the respondents claim that medical professionals improve their qualifications as a result of their work abroad. Nurses are less optimistic in this respect: about one-third of the nurses and half of the doctors share this opinion.

43Labor migration does not only exert a beneficial influence on the financial situation of migrants and their families; it also poses a risk to their personal lives. A long-term separation from their families and new social relations may lead to marriage breakdown and inflict emotional damages as well as financial losses on those family members still residing in Tajikistan, who entirely depend on the money sent by the migrant. Only approximately 10% of the respondents, however, believe that this risk is high and that family breakdown affects most migrants.

44Furthermore, there is another threat arising from their status of foreigners in the host state and the resulting discrimination, humiliation or even aggressive attitudes of locals, which migrants may face at their work place as well as in their everyday life. According to approximately 20% of the respondents, most migrant workers experience discrimination. Approximately 40% the respondents suppose that such cases are quite rare, and approximately 25% of them think that there is no such risk.

45In summary, many respondents assume that labor migration positively affects all aspects of health care workers’ lives: it mainly leads to an improvement in their financial situation (personal and family one), results in an improvement in their professional qualifications (i.e. it provides opportunities for higher remuneration and career progress), and poses little risk to their personal prosperity. The qualitative research findings also paint a positive picture of the migrant life of medical professionals. They encounter difficulties mainly in finding employment in their specialty and in adapting to their new job and an unfamiliar social environment.

Discussion

46The study revealed that health workers consider their education, and employment opportunities offered by the private clinics and available vacancies in the state health facilities as an advantage of the existing healthcare system. Growing private sector demonstrates rational management solution of the Tajik Ministry of Health and Social Protection to address migration of the health professionals. Equipment in health care units were mentioned by some nurses (approximately 20%) and few doctors (5%) as an advantage of the Tajik health care system. At the same time the majority of the respondents named low wage, lack of the equipment and shortage of the health personnel as weakness of the healthcare system.

47The quantitative research data enable to construct the social profile of potential labor migrants among medical professionals. They are mainly married male doctors aged between 30 and 50, working in Dushanbe, specialists in anesthesiology, surgery and cardiology.

48Despite the positive attitude of 60% of the respondents about migration only half of them have undertaken particular actions in seeking and finding employment abroad. Low wage indicated as the main cause for migration. Family circumstances were mentioned by the respondents as push and retain factors at the same time. But among retaining factors family reasons are placed in the first rank. Poor working conditions – third reason for seeking a job abroad. Doctors are interested in seeking job abroad twice often than nurses, men more interested in migration than women.

  • 13 Interview with Vera Skorobogatova, head of the Glavexpertcenter of the Russian Federal Control Serv (...)

49The Russian Federation was indicated as the main country of destination which is not surprising. Common history, language, familiarity with healthcare system and similar approach in medical education are factors that attract health professionals. Besides the remuneration in the Russian Federation is much higher than in Tajikistan. The Russian Federation is also facing a shortage of the health professionals particularly in the rural areas (Kuznecov, Kalinin, Trusova, Rasskazova, 2014). The conditions for work there are assessed as not satisfactory for the local health workers but acceptable for the foreigners including Tajik health providers.13 Yemen and Afghanistan were also indicated by the respondents but due to the instable political situation are less attractive for the Tajik health professionals. Working in Western European countries demands visa, knowledge of the foreign language and passing a certification process to prove medical qualification which is a complicated and expensive procedure.

50Research demonstrated that respondents prefer to make informed decision about migration: only being sure that they have collected all the required documents and enough money for the initial period of adaptation. The health professionals ultimately intend to have a regular status abroad.

51At the same time, for approximately one third of respondents making a decision is not easy due to a number of concerns such as securing the employment, expensive daily living costs, changes in the working environment, fear of stigma and discrimination as foreign born specialists, marriage breakdown as a result of the long-term separation from the families, the potential emotional damages and financial losses on their family members remaining in Tajikistan, who entirely depend on their financial or family support.

Conclusions

52The following conclusions and recommendations for addressing the migration challenges faced by the health professional workforce can be proposed on the basis of the research findings:

  • Increasing the average salary on a regular basis. It is important that the raise should considerably surpass inflation rates and price increases in order to produce tangible results. In the qualitative research, on several occasions there was expressed the opinion that previous salary increases were accompanied by several rises in prices and did not actually induce any changes in the living standard of medical professionals. Taking into consideration their expectations about remuneration abroad, we assume that the average salary should be initially increased to usd 500 per month. Introduced by the Tajik Ministry of Health and Social Protection benefit package aimed to reduce informal payments by establishing transparent system of payments shifting it to formal as a co-payments need further development based on the lessons learned during piloting phase.

  • Awarding additional bonuses to medical professionals working in difficult conditions and in unattractive areas of the country.

  • Enhancing additional income opportunities by regulated private medical practices and private health care facilities.

  • Providing modern medical equipment in health care facilities.

  • Providing opportunities for further improvement of professional qualifications, and the expenses, incurred therefore, being covered by the state budget or a special fund.

  • Developing a mechanism for labor migration management (via signing international agreements with host countries and establishing special administrative units), which will enable its being monitored. The economic situation in Tajikistan does not provide grounds for believing that the migration rates will decline naturally in the near future. Furthermore, bans and restrictions are not applicable in present conditions neither they offer an effective solution.

  • Establishing network and collaboration with the emigrated health professionals and involve them to the research, professional development and other activities to address the needs of the Tajik health care system.

53The research demonstrated that the migration of health professionals is part of the economic migration trend typical for modern Tajikistan. Tajik health authorities recognize the issue and tries to address the main push factor – low wages. Ministry of Health and Social Protection of the Republic of Tajikistan piloting innovative approaches to increase the salary of the medical staff by introducing a benefit package to decline out of pocket payments, through collaboration with the local authorities providing incentives in rural areas such as land, by developing private health sector. Reforming the financial healthcare system by establishing a mechanism of payment on per capita basis in the primary healthcare system and casebased payment at the hospital level are also considered by the government of Tajikistan as a plausible option to contribute to increasing the wages of medical workers. Attracting emigrated health professionals to address the needs of the healthcare system of the Republic of Tajikistan need to be a part of the migration management. Extending collaboration with the Russian Federation as a main country of destination is important for the mapping and creating a databank of the Tajik health workers for further utilizing their knowledge and skills within the framework of the national strategy on engaging diaspora for developing the Republic of Tajikistan.

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Notes

1 Agency for Statistics under the President of the Republic of Tajikistan. Statistic of the labour migration in the Republic of Tajikistan. Retrieved from http://www.cisstat.com/ cis_Labourstat/CIS_Labourstat_2_27-2%202015%20Bishkek%20Statistics%20of%20 labor%20migration%20in%20Tajikistan.pdf

2 Agency for Statistics under the President of the Republic of Tajikistan. Statistic of the labour migration in the Republic of Tajikistan. Retrieved from http://www.cisstat.com/ CIS_Labourstat/CIS_Labourstat_2_27-2%202015%20Bishkek%20Statistics%20of%20 labor%20migration%20in%20Tajikistan.pdf

3 Interview with Mihail Murashko – head of the Roszdravnadzor. Rossiyskaya Gazeta, Federalniy Vypusk. №7294 (128). Retrieved from https://rg.ru/2017/06/14/roszdravnadzorinostrannyh-vrachej-privlekaet-zarplata-v-rossii.html

4 who. Regional Office for Europe. Evaluation of the Structure and Provision of Primary Care in Tajikistan. A survey based project. October, 2014.

5 Ibid.

6 Having a population of more than 50,000 people (Dushanbe not included): Hudjand, Kulyab, Kurgan-tube, Istaravshan.

7 Having a population of less than 50,000 people.

8 With respect to the high rates in Gorno-Badakhshan (gbao), we should mention again and take into consideration the fact that these results are based on interviews with ten people only. Therefore, they do not represent a sufficient sample to provide enough quantitative data for analysis.

9 Migracionnaâ situaciâ v Rossijskoj Federacii i khod realizacii dokumentov, prinâtykh v ramkakh Sodružestva Nezavisimykh Gosudarstv, v sfere migracii [Migration situation in the Russian Federation and the progress of the documents adopted within the framework of the Commonwealth of Independent States in the Field of Migration]. Available from http:// www.e-cis.info/page.php?id=19703

10 National Bank of Tajikistan – Statistics, Real sector, Wages (http://www.stat.tj/en/library/wages.xls), Rosstat, Informaciâ o social’no-èkonomičewskom položenii Rossii – 2010 (http://www.gks.ru/bgd/free/B10_00/Main.htm)

11 World Bank – data, indicators, healthcare (http://data.worldbank.org/indicator/SH.XPD.totL.ZS)

12 Ministry of Health and Social Protection of rt. Joint Annual Review. National Health Strategy for 2010-2020. Period of 2010-2015. Mid-Term Review. Report #5. Dushanbe, 2015. Page 68.

13 Interview with Vera Skorobogatova, head of the Glavexpertcenter of the Russian Federal Control Service on Education and Scienceю “How to acknowledge foreign diploma in Russia” («Как признать зарубежный диплом в России»). Available from http://www. mk.ru/social/2016/06/06/kak-priznat-zarubezhnyy-diplom-v-rossii.html

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Table des illustrations

Titre Figure 1Doctors’ specialty (N=222)
URL http://journals.openedition.org/asiecentrale/docannexe/image/4194/img-1.jpg
Fichier image/jpeg, 636k
Titre Figure 2Attitude towards the opportunity to work abroad in the same professional field
URL http://journals.openedition.org/asiecentrale/docannexe/image/4194/img-2.jpg
Fichier image/jpeg, 596k
Titre Figure 3Attitude towards the opportunity to work abroad in the same professional field, by region
URL http://journals.openedition.org/asiecentrale/docannexe/image/4194/img-3.jpg
Fichier image/jpeg, 620k
Titre Figure 4Average salaries, Tajikistan and Russia, 2010 (in usd)10
URL http://journals.openedition.org/asiecentrale/docannexe/image/4194/img-4.jpg
Fichier image/jpeg, 612k
Titre Figure 5Monthly salaries in usd
URL http://journals.openedition.org/asiecentrale/docannexe/image/4194/img-5.jpg
Fichier image/jpeg, 644k
Titre Figure 6Is your monthly salary enough to cover your needs?
URL http://journals.openedition.org/asiecentrale/docannexe/image/4194/img-6.jpg
Fichier image/jpeg, 604k
Titre Figure 7Expenditures for healthcare. Countries of the Central Asia and Russian Federation, 201011
URL http://journals.openedition.org/asiecentrale/docannexe/image/4194/img-7.jpg
Fichier image/jpeg, 648k
Titre Figure 8Retention factors of the migration of the health professionals
URL http://journals.openedition.org/asiecentrale/docannexe/image/4194/img-8.jpg
Fichier image/jpeg, 706k
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Pour citer cet article

Référence papier

Ilhom Bandaev, Rukhshona Kurbonova et Marya Samuilova, « Tajik healthcare workers on the move: causes, consequences and responses »Cahiers d’Asie centrale, 27 | 2018, 305-330.

Référence électronique

Ilhom Bandaev, Rukhshona Kurbonova et Marya Samuilova, « Tajik healthcare workers on the move: causes, consequences and responses »Cahiers d’Asie centrale [En ligne], 27 | 2018, mis en ligne le 01 janvier 2020, consulté le 22 septembre 2020. URL : http://journals.openedition.org/asiecentrale/4194

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Auteurs

Ilhom Bandaev

Head of the Republic Clinical Center of the Family Medicine of the Ministry of Health and Social Protection of the Republic of Tajikistan, former head of the Department of the international relations and reforming of the primary health care of the Ministry of Health and Social Protection of the Republic of Tajikistan.

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Rukhshona Kurbonova

Migration Health Programmes Coordinator, Migration Health Unit of the iom in Tajikistan.

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Marya Samuilova

Migration Health Unit of the iom Regional Office in Brussels.

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