Migration is a key issue for nursing. According to the International Organization on Migration (IOM), there were 214 million international migrants in 2005, which represents 3.1% of the world’s population. Of this number, 49% were women (IOM, 2010). People, including nurses, move around for many reasons: to work; to study; to have fun; to receive health care; or to escape violence, poverty, persecution, and famine in their native countries. This movement brings with it the problems of unemployment, discrimination, racial tension, and harmful cultural practices, such as female genital mutilation. Today’s nurses must understand health, illness, and coping mechanisms from the perspectives of many cultures. Equally important is the need for the profession to be an advocate for sound health and nursing policy that considers the well-being of the patient along with that of the profession and its practitioners.

Governments—bilaterally, regionally, or through the WTO—negotiate terms for the movement of goods and people for economic gain. With the global shortage of health professionals, individuals and institutions at all levels (i.e., governments, employers, policymakers, the public, the professions, and professionals) are interested in the movement of nurses. It affects policy, planning, and delivery of nursing education and patient care. It brings to the fore such issues as use of fraudulent credentials, ethical recruitment, and discriminatory workplace policy and practice.

While nursing migration has slowed recently, nurses are still on the move. The nursing community has been vocal nationally and internationally in addressing migration and workforce policy and practice. The following are examples:

Migration and the shortage of health personnel have placed human resources for health care on the agenda as never before. In 2004, the Joint Learning Initiative (JLI) reported an estimated shortage of 4 million health workers globally. This figure is based on the density of 2.5 health workers (physician, nurse, midwife) per 1000 population that is required to achieve 80% coverage of measles immunization and skilled attendants at birth (JLI, 2004). It was supported in 2006 in the World Health Report, which identified 57 countries as falling below this threshold, 36 of them in sub-Saharan Africa (WHO, 2006). The crisis also saw the launch of the Global Health Workforce Alliance, a partnership with national governments, finance institutions, health workers, international agencies, professional associations, academic institutions and civil society, dedicated to identifying and facilitating solutions to the human resource crisis (GHWA, 2006). It champions universal access to health care and the message that a skilled, motivated, and supported health force is the cornerstone of a robust health system.

Attention to “health human resources” is part of the Millennium Development Goals (MDGs), launched in 2000. With a target date of 2015, the eight MDGs address poverty, education, women, child mortality, maternal health, HIV and malaria, the environment, and a global social compact (UN, 2005). Achieving the MDGs ultimately affects the health and well-being of the world’s 6.8 billion people. Governments and others (e.g., the G8, made up of the heads of state of Canada, France, Germany, Italy, Japan, Russia, the United Kingdom, and the U.S.) who meet annually to deal with major national and international economic and political issues recognized that these ambitious goals could not be met unless two key issues were addressed: Africa and the global health human resource crisis, particularly the nursing shortage.

Today nearly all nations face a nursing shortage brought about by increasing demand and diminishing supply, an aging nursing workforce, a shortage of other professional and ancillary staff, increasing acuity of illness, a poor image of nursing, and continuing health sector reform. For Africa, HIV/AIDS further complicates the shortage. Shortages vary by field of nursing, geography, level of care, sector, and organization; but one commonality exists: there are two shortages—a real shortage and a pseudo-shortage.

Pseudo-shortages exist in both developed and developing countries and occur when there are enough nurses in the country but when posts are not funded and/or nurses are not willing to work under the conditions available. For example, South Africa is said to have 31,000 vacant public sector nursing posts and 35,000 unemployed nurses. The lack of a positive practice environment (low salaries, poor benefit packages, lack of supplies and equipment, inadequate nurse/patient ratios, unsatisfactory patient and staff safety, lack of access to professional development and promotions, lack of family-friendly policies, and lack of decision-making input) remains the most critical element everywhere and particularly in Africa.

Africa is in dire straits. As former Prime Minister Tony Blair noted, “Africa is the only continent which, without change, will not meet any of the Millennium Development Goals” (Blair, 2005). While mortality rates are improving, in 2008 the mortality rate among children under 5 years of age in sub-Saharan Africa was 144/1000 live births compared with 6/1000 in industrialized countries (UNICEF, 2009). This means that an Ethiopian child was 30 times more likely to die by age 5 than a child in Western Europe (UNICEF, 2010). In 2008, malaria killed approximately 850,000 people, 90% of which were in Africa, mostly among children under 5 years of age (UN, 2010). In 2008, over 30 million African children were not attending primary school (UN, 2010), and 14 million were AIDS orphans (UNAIDS, 2009b).

During this past decade, successive meetings of the G8 have focused on aid to Africa. In 2005, they agreed to increase annual aid to Africa by $25 billion per year and overall aid by an estimated $50 billion by 2010. They have since reaffirmed these commitments as well as specific commitments for health and the health workforce, especially in Africa (DFID, 2009; Guebert, 2009). It will be important that nurses and other stakeholders monitor and lobby national governments to keep these commitments. Ultimately, we need to decrease poverty and increase health for all nations.

Today, poverty is the world’s most devastating scourge. The World Bank estimates that there are about 1.4 billion extremely poor people in the world, with women representing 70% of the absolute poor (World Bank, 2008). According to the UN Secretary General, the number of extreme poor in sub-Saharan Africa has risen by 92 million between 1990 and 2005, and by 8 million in West Asia. Children living in absolute poverty are 5 times more likely to die before the age of 5 than children who are not poor (WHO, 1999). Every day, almost 16,000 children die from hunger-related causes—1 child every 5 seconds; and 947 million people in developing countries are undernourished—a condition that affects one’s health and well-being, hinders fetal development, and contributes to mental retardation (Bread for the World, 2009) (Box 101-4).

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