Potential of China in global nurse migration

Health Services Research, June, 2007 by Zhiwu Zack Fang

China has a population of 1.3 billion people and represents one of the world's largest reservoirs of human resources. Because of the relative isolation from global commercial activities until the last two decades, its potential for supplying labor for global markets is only now beginning to emerge. The purpose of this paper is to examine what is known about the nurse workforce and nursing education in China, in order to assess the likely potential for nurse migration from China in the future.

There are over 18,000 hospitals, 2 million physicians, and 1.3 million working registered nurses in China (Jiang, Shen, and Yan 2004), i.e., one nurse for every thousand people. As a comparison, the United States has one nurse for every hundred people. Further, there are 0.4 registered nurses per hospital bed in China (Mao 2004), and only 0.68 nurses for each physician in the hospitals (Jiang, Shen, and Yan 2004). The Chinese Ministry of Health set the standard at two nurses per physician, but few hospital budgets can meet this standard (Study Group [MOH] for Nursing Demand 2003; Nie, Li, and Jia 2004). Key Statistics of Chinese Nursing offer a summary of the workforce statistics (Table 1).

However, despite the shortage, China has not invested enough funding in health care to employ the nurses that have been educated. Many Chinese nurses either cannot find a job or are concerned with losing their jobs (Wu and Zhang 2000). A large number of new nursing graduates struggle to find jobs even at a salary level as low as U.S.$3,000 per year. And frequently, nurses older than 50 years of age start to lose their positions to younger competitors, despite their greater experience (Liu and Sun 2003). Thus China currently appears to have a surplus of nurses, but only in terms of budgeted positions.

Overall, China has under invested in nurses relative to the size of its population and health care needs and in terms of the supply of physicians, which contrary to WHO recommendations, exceeds the number of nurses. If more funds were invested in health services, the country would require more nurses. The extent of a nurse surplus in China will depend upon the extent to which the health care system is expanded to better meet domestic needs.

EMPLOYMENT ISSUES AND MIGRATION OF CHINESE NURSES

The current level of unemployment among nurses has created an interest in migration motivated both by individual choice and government policies to maximize remittance income. Nurses themselves express concerns over low wages, working conditions, and lack of job security.

Surveys indicate that only 58 percent of Chinese RNs feel "relatively satisfied" or "satisfied" with their jobs (Sun and Yan 2001). Nursing as an occupation falls in the "below-average" salary category in China. In most regions and cities in China, the average salary for a nurse with 3-10 years working experience is only around U.S.$200 per month. With more than 15 years of experience, the average is about U.S.$300 per month. In the coastal areas, Shanghai for instance, salaries can be slightly better, but come with a higher cost of living. Compared with nurses, Chinese physicians have more revenues of income beside basic salary, and can easily earn three to five times more.

In addition, nurses in China have to carry a very heavy workload (Wu and Zhang 2000; Wang and Dai 2004; Zhang and Ren 2004). Compared with U.S. nurses, employed Chinese nurses are faced with 10 times the population responsibility. Hospital demand is for younger nurses (Peng 2004), as they are paid less and can handle more physically demanding work loads. As a result, age discrimination is also a problem and it is not unusual to find hospitals dismissing most nurses older than 45 years of age.

International migration of nurses began about 15 years ago where the Chinese government began organizing groups of English-speaking nurses to work in Singapore and Saudi Arabia. Hundreds of Chinese nurses leave China to work in these countries every year, under a government arranged contract. The Chinese government charges 10-15 percent of their annual salary as the "handling fee" for such an arrangement. These contracts usually last about 2-3 years, and most nurses return to work in their original hospitals. In many cases, the "returning" is required and clearly stated in their contracts.

Over the past 5 years, there has been a similar increase in the number of nurses who migrate to Australia and England, especially after these countries lowered entry requirements. Most of these migrations are arranged by private companies, instead of government agencies. Because these operations are "for profit," the nurses are usually required to pay a significant amount of money to the company in exchange for the service. These "fees" vary anywhere from U.S.$4,000-15,000, equal to the sum of a Chinese nurse's salary over many years. The majority of nurses are not able to afford the fees, even if they are qualified in English and clinical skills. For many, the only option is to borrow money from family and friends, counting on a career future with 10-20 times higher income. In the United States, there has been a significant increase in the level of interest in recruitment from the Chinese market from a variety of sources including hospitals, staffing agents, educational institutes, and private head hunters, but the numbers remain small.