The Global Health Care Chain: From the Pacific to the World (review)

John Connell's finely researched and informative book is a Pacific regional companion to his 2008 edited volume The International Migration of Health Workers. The Global Health Care Chain: From the Pacific to the World draws on a survey of more than five hundred health workers in nine island states—Kiribati, Marshall Islands, and Palau in Micronesia; Fiji and Vanuatu in Melanesia; and Cook Islands, Niue, Sāmoa, and Tonga in Polynesia-and three destination states—Australia, Canada, and New Zealand. He also pulls together a large literature including academic studies and technical reports by international agencies. Beginning with an overview of globalization of skilled migration as it affects the Pacific, the book contextualizes the rise of Pacific migration, examines various health care systems in the Pacific, describes how skilled health workers are trained in the various Island states, considers why these workers decide to migrate or stay at home, and analyzes the impacts of their migration choices on Island health services.

Globalization draws the highly skilled from every corner of the world to the metropolitan centers that offer the best working conditions and pay—a negative trend for the health systems of less-developed countries and especially for the small Island states of the Pacific. Health professionals are among the most expensive to train and have the easiest access to overseas job markets, not only in Australia and New Zealand but also in the Arabian Gulf states and Canada. Some Pacific Island states recruit from within the Pacific, as well as from other developing countries. For example, Fijian nurses work in the Marshall Islands and Palau, and Samoan doctors work in American Samoa. Men and women from Pacific Island communities where nursing was once seen as demeaning or unmanly now regard it much more positively because of the overseas employment opportunities it offers.

Higher wages are not the only reason for leaving, or for not returning after training. Returning graduates are often as frustrated by their working conditions as they are by their salaries. Small, poor countries lack the medical equipment and other resources that encourage professional development, and few can support highly specialized staff. Migration-prone Pacific Island states also have the problem of meeting rising expectations, knowing the life-extending technologies available to their relatives overseas and wanting them at home. But providing specialized facilities for renal or cardiothoracic or oncology care is likely to mean fewer basic services in rural areas, and overseas treatment schemes, unless donor funded, eat up health-sector budgets. Keeping professionally qualified health staff in remote rural areas is a challenge for all Pacific Island states, where not only nationals may refuse to serve but also doctors recruited from other developing countries. In some states this is related to poor governance, where health centers and rural hospitals have been allowed to become dilapidated, lacking drugs and equipment, with staff salaries sporadically paid.

The book explores in detail how skilled health workers make decisions to migrate or remain at home and provides a number of illustrative case studies from the survey on the options and dilemmas of skilled health workers. Family considerations are prominent in many of these accounts, particularly among Islander nurses; by staying they may directly care for their families but by going they may provide them with material support. Some choose both options, alternately working abroad and at home.

Connell critically examines the various policy options open to Pacific Islands governments, such as the rationing of training by offering less internationally marketable credentials, offering salary supplements, improving workplaces, and bonding graduates trained in health sciences abroad. Should small Island states train more intermediate paramedical staff than doctors, even when paramedics are unwelcome among local people who want "real" doctors? Should they change the rules to allow nurse practitioners and...