Retaining care workers will become more difficult for Asia’s ageing economies.
Lizalyn never thought she would be the kind of person who actively made migration plans. When the 30-year-old nurse moved from the Philippines to Singapore in 2008, it felt more like a leap of faith. Although she knew nothing about Singapore, Lizalyn had sent in an application and was immediately hired.
A decade later, Lizalyn is carefully planning her next move. Nurses are still in short supply in Singapore’s hospitals, but wages in the country’s healthcare system remain far below those of countries like the US and the UK. Lizalyn’s plight is like that of many other migrants in Singapore–her work visa does not allow her to sponsor dependants like her husband. After two failed attempts at gaining permanent residency, she had decided to apply for a position in Germany.
At that time, dozens of Lizalyn’s foreign colleagues had already left Singapore. Even though Lizalyn’s nurse manager tried to convince her to stay, she decided that moving was a better option for her family. She left Singapore in 2021 during the second year of the COVID-19 pandemic.
Lizalyn’s story reflects an understudied dilemma amid how researchers have made sense of care workers’ movement across borders. In tracing international migration, scholars have tended to focus only on two places: the destinations that benefit from the influx of foreign workers and the source countries that they leave behind. Few realise that there are other nations between these two places–locations that serve as attractive ‘stops’ along the way, but remain unlikely places to stay.
In this article, I highlight the problems faced by these intermediate locations– countries that workers move through before they reach their final destinations of choice. I use the case of care workers to argue that as global care needs rise, these places will also become vulnerable to serious labour shortages unless governments work to attract and retain care workers. To date, the number of countries facing this dilemma has only continued to grow, encompassing wealthy Asian economies like Singapore, Japan, and Korea.
I end this article with three suggested changes that countries and organisations could consider in improving their appeal to care workers in this race for such talent. While pay is one of them, I highlight two other aspects which will go a long way to attract foreign care workers.
PROBLEMS IN THE CARE CHAIN
In making sense of care workers’ migration patterns, scholars have used a prominent framework termed the ‘global care chain’.1 This framework argues that as more women enter the workforce within wealthy nations, families increasingly outsource care and household labour to migrant women, mostly from poorer countries in the Global South. Then, as these women leave their children to work abroad, their families might seek another woman from a poorer part of the country to take her place. Scholars argue that as we move down this chain of care labour, the exchange value of such work decreases until it eventually becomes unpaid. In this story, care is a resource extracted from the disadvantaged countries, mainly for the benefit of more privileged nations at the top of the chain.
While this framework helps us understand how care can be unevenly distributed around the world, it does not adequately explain how people move through the different countries that comprise this care chain. Much focus is placed on the lack of care within origin countries and the ‘care surplus’ within the destinations where these workers end up. However, we actually know very little about what this means for nations located in the middle of these two places.
As such, recent studies have moved beyond the care chain to look more closely at how individual migrants plot their migration journeys. Researchers found that instead of simply moving straight to their desired destinations, migrants are more likely to make incremental steps through other countries first, accumulating the resources needed to reach their target destinations. Anju Mary Paul, a sociologist from New York University Abu Dhabi, describes this practice as a form of ‘stepwise migration’.2
In many ways, stepwise migration makes sense in a world where immigration has become much more costly and bureaucratic. Gaining entry into countries that offer higher wages and residency status is often a difficult endeavour, requiring massive investments of both time and money. For healthcare professionals, popular destinations like the US require clearing expensive examinations and years of clinical experience. Paul argues that stepwise migration is a common strategy that both low-wage and highly-skilled migrants use in navigating all these challenges.
However, in many countries, the assumption of continuous stepwise migration can undermine sustainable policies in attracting and retaining care workers.
CHOOSING NOT TO COMPETE FOR CARE WORKERS
Countries within Asia have come to rely heavily on foreign care workers such as nurses, caregivers, and domestic workers. Yet, state policies within the region have mainly treated these migrants as temporary visitors. Across the region, few care workers are entitled to sponsor family members as dependants and, often, applying for citizenship is notoriously difficult.
Geographer Margaret Walton-Roberts argues that such policies have encouraged healthcare professionals like nurses to see certain countries as only short-term stints along their migration journeys. In a recent article on Singapore, she wrote that while migrant nurses saw the country as “offering the potential to move on to other more desirable migratory locations”, the low chance of being granted permanent residency also made Singapore only “a temporary stop”.3
There are many reasons for such restrictions. Small nations may not have the capacity to absorb too many new citizens and temporary migrants provide a cheaper form of labour for local employers. Others argue that care work is simply devalued. While some states may readily grant permanent residency to technical or corporate professionals, nurses are often seen as ‘semi-skilled’ workers.
Whatever the case may be, underlying such policies is the belief that there will always be a fresh supply of foreign care workers who will come into the country. Nurses like Lizalyn may come to gain more hospital experience. Meanwhile, others may be looking to earn more money than they do at home. Even if these nurses eventually leave for more desired destinations, the assumption is that others will take their place. As such, rather than competing with larger destinations like the US or Canada, countries in the middle of the care chain often rely on an influx of new workers to deal with the constant attrition within hospitals and homes.
Unfortunately, these governments can no longer take for granted a continuous supply of care workers. This is because care workers like nurses have more choices now than before.
SKIPPING OVER THE STEPPING STONES
Stepping stone destinations are starting to feel the strain of labour shortages. First, as healthcare needs have grown in wealthy nations, desired destinations have loosened requirements for entry, allowing foreign care workers to ‘skip’ places in the middle of the care chain. Even before the pandemic, the UK had rescinded the requirement for all foreign nurses to have at least 12 months of clinical experience.4 Such changes allowed care workers to move straight from the Philippines towards their desired destinations, without the need to make incremental steps towards other countries.
In contrast, stepping stone destinations like Singapore and Japan have been hesitant to adjust their own skills requirements despite growing competition from other nations. In Singapore, foreign nurses must have at least three years of experience in a tertiary hospital with at least 100 beds in order to qualify for a staff nurse position. Because such institutions are rare in places like the Philippines, Filipino nurses who move to Singapore are often demoted to lower positions, such as that of an enrolled nurse. This requirement remains even as local hospitals continue to raise alarms of serious shortages in their wards.
It is interesting to note that tertiary hospital experience actually qualifies foreign nurses for positions in the US and the UK as well. As such, those who have these qualifications would rather invest in moving straight to these Western destinations, rather than spending a few years working in stepping stone countries such as Japan.
Meanwhile, the passing rate for foreign nurses in the Japanese nursing board examinations has remained below 10 percent, mainly because of difficulties in passing the language requirement for practice.5 Such trends are concerning, given that the Japanese government has specifically established bilateral agreements with the Philippines and Indonesia to allow for the entry of foreign nurses and healthcare workers into Japan. Given the dismal number of foreign healthcare workers being successfully recruited through this agreement, analysts have declared it a case of policy failure and recommended that Japan shift towards the same recruitment criteria used by the US instead.6
Even worse, source countries are starting to restrict the number of care workers deployed overseas. During the pandemic, former Philippine president Rodrigo Duterte had imposed a ban preventing its nationals in 13 healthcare professions from working overseas.7 While the ban was eventually lifted in 2021, the government continues to impose a cap of 7,500 nurses who can leave for overseas jobs every year. To put things in perspective, this number is a far cry from the 25,000 nurses who left the country in 2019.8
Beyond nurses, the Indonesian government has imposed its own ban on the deployment of domestic workers–mainly as a means of pressuring destination countries to improve work conditions and social protection.9 Similar policies had been imposed by other source countries like Myanmar and Sri Lanka as well.10 Such uncertainties call into question how sustainable it is to rely on a steady influx of care workers.
WHAT NEEDS TO CHANGE?
Ageing economies within Asia need care workers to sustain everyday life, but there is often a mistaken assumption that competing with countries higher up the care chain is only about raising wages. Drawing from migration research on care workers, I outline three ways through which both policymakers and employers can mitigate future labour shortages.
1. Prioritise care needs in migration policy
As labour shortages become more acute, policymakers in stepping stone destinations may need to re-evaluate their treatment of care workers as only ‘temporary’ migrants. Nurses are a popular example but there are other forms of care as well that keep a society running. Similar examples in this category include early childhood educators, service professionals, and even domestic workers.
Recruiting migrants based on ‘talent’ is not unprecedented within Asia. But that recruitment is largely for workers with technological knowledge and skills. For example, in Singapore, a new category of work visa called Tech.Pass was issued to “attract founders, leaders and technical experts with experience in established or fast-growing tech companies, so as to contribute to the development of Singapore’s tech ecosystem”.11 The pass also allows the visa holders to bring immediate family members, such as their spouse, children, and parents, to stay in Singapore on either the dependant’s or long-term visit pass. These passes are issued by the Ministry of Manpower, Singapore’s government body responsible for developing and implementing labour policies related to the workforce in the country. Politicians have justified these efforts because of the economic returns associated with technical skills. Along the same vein, it is within reason that immigration policymakers could consider according selected categories of care workers the same privileges if they want to attract more of these workers.
While care work may not have direct monetary contributions to a nation’s economy, scholars have long argued that productivity depends on the reproductive labour that keeps workers alive, healthy, and thriving.12 In today’s society, such work includes a wide range of tasks–from feeding the family and managing a household to attending to people’s physical and mental ailments. It is important for nations to properly value and retain the workers who fulfil these needs.
2. Recognise and protect care workers
Policymakers and employers must also recognise that care work is a skill that should be given proper recognition and support. While migrants are motivated by the opportunity to earn higher wages, they also seek employment that values their abilities and rewards them accordingly.
In my own work on Filipino nurse migrants, interviewees often emphasise the time and effort they have invested in honing their clinical skills. When they feel that such skills are devalued or misrecognised, they feel compelled to look for other places to practise.
In 2021, I began conducting a series of preliminary interviews with Filipino nurses who migrated from Singapore to other destinations like the US, the UK, and Australia. One factor they cited was the perceived disparities in salaries between foreign and locally-educated nurses. However, another important reason was that these nurses wanted to be promoted to a position that recognised their four-year degrees. This is not to say that there is no discrimination or misrecognition in destinations like the US and the UK. However, my interviewees took solace in the assurance that once they passed the necessary examinations, they could begin work as registered nurses. In contrast, this status is not easily obtained in Singapore.
The question of how to properly recognise care skills is also becoming an important issue for domestic workers and live-in caregivers. As wealthy societies start to age, employers turn to migrant women in caring for elderly parents and relatives. Li-Fang Liang, a sociologist from National Dong Hwa University, has documented how training centres in Indonesia spend an increasing amount of time preparing workers to care for the elderly, with countless hours devoted to tasks such as feeding, bathing, and emergency care.13 Yet many employers remain hesitant to increase the monetary value attached to such skills. Taiwan has done well in recruiting caregivers due to the high rates for such services. However, other destinations like Singapore remain far behind in terms of compensation. Developing a system that provides clear rewards for specialised skills will not only attract more migrant care workers, but also convince them to stay.
3. Provide for non-economic needs too
Care workers, like the rest of us, seek places that offer stability and a sense of belonging. Attracting care workers need not merely be about offering more money. As migration studies show, workers can be compelled to stay when a place allows them to achieve personal development, establish a community, and find dignity in their work.
While some migrants may initially move to a country as a stepping stone, welcoming policies could entice them to stay. In Singapore, it is therefore heartening to learn that the Ministry of Health is considering granting permanent residency to good performers, given the intensified global competition for nurses.14 Beyond the instrumental benefits of permanent residency, this practice would also help foreign healthcare professionals feel valued in their host country, and eventually, more committed to staying there.
In the case of domestic workers, simple measures such as allowing for days off can have a significant impact on individual health and well-being. To encourage more nations to enact such policies, scholars have moved towards finding ways to quantify how nations value care labour. A recent proposal for a Global Care Policy Index suggests drawing comparisons among countries in order to determine how much incentives and protections are given to care workers.15 Perhaps seeking to improve on these indicators can serve as a small step towards attracting care workers.
CONCLUSION
Ageing demographics and falling fertility rates have long been pressing issues for Asian nations. The COVID-19 pandemic has only made things worse and heightened the need to create a sustainable pool of care workers within a country.
For too long, policymakers and employers within the region have relied on the assumption that there will always be migrants willing to come and work, even if they are doing so only as a stepping stone to other destinations. This needs to change. Countries in the middle of the care chain will only face more disruptions when recruiting workers, especially as desired destinations adjust skills requirements and source countries tighten emigration controls. Many governments already have clear policies for attracting highly skilled migrants. It is time that we come to see care as a skill to value, attract, and retain.
Dr Yasmin Ortiga
is Assistant Professor of Sociology at the School of Social Sciences, Singapore Management University
Endnotes
1. See for example Rhacel Salazar Parreñas, “Servants of Globalization: Women, Migration and Domestic Work”, Stanford University Press, 2001; Arlie Russell Hochschild, “Global Care Chains and Emotional Surplus Value” in “Global Capitalism”, edited by W. Hutton and A. Giddens, The New Press, 130-146, 2000.
2. Anju Mary Paul, “Multinational Maids: Stepwise Migration in a Global Labour Market”, Cambridge University Press, 2017.
3. Margaret Walton-Roberts, “Bus Stops, Triple Wins and Two Steps: Nurse Migration In and Out of Asia”, Global Networks, 21(1), 2323-2330, 2021.
4. Nicola Gillin and David Smith, “Overseas Recruitment Activities of NHS Trusts 2015–2018: Findings from FOI Requests to 19 Acute NHS Trusts in England”, Nursing Inquiry, 27(1), e12320, 2020.
5. Republic of the Philippines Department of Labor and Employment, “Filipino Nurses Increase Passing Rate in Nursing Exam JPEPA to 8.8%”, March 31, 2015.
6. Nozomi Yagi, Tim K. Mackey, Bryan A. Liang, et al., “Policy Review: Japan–Philippines Economic Partnership Agreement (JPEPA)– Analysis of a Failed Nurse Migration Policy”, International Journal of Nursing Studies, 51(2), 243-250, 2014.
7. Yasmin Y. Ortiga, Michael Joseph Diño, and Romeo Luis A. Macabasag, “Clocking Out: Nurses Refusing to Work in a Time of Pandemic”, Social Science & Medicine, 305, 115114, 2022.
8. CNN Philippines, “Marcos to Raise Deployment Cap of Nurses Abroad”, September 1, 2022.
9. Teh Athira Yusof, “Call Off Maid Online System to Lift Indonesian Worker Ban”, New Straits Times, July 13, 2022.
10. See for example, Aw Cheng Wei, “Myanmar Slaps Fresh Ban on Maids for Singapore”, The Straits Times, June 5, 2015; Shihar Aneez, “Sri Lanka to Gradually Ban House Maids Abroad amid Abuses, Social Cost”, Reuters, June 2, 2016.
11. EDB Singapore, “Tech.Pass to Attract Entrepreneurs and Leaders to Develop Singapore’s Status as a Tech Hub”, November 12, 2020.
12. Barbara Ehrenreich and Arlie Russell Hochschild, “Global Woman: Nannies, Maids, and Sex Workers in the New Economy”, New York: Henry Holt and Company, 2002.
13. Liang Li-Fang, “The Making of an ‘Ideal’ Live-In Migrant Care Worker: Recruiting, Training, Matching and Disciplining”, Ethnic and Racial Studies, 34, 1815-1834, 2011.
14. Joyce Teo, “24k More Nurses, Healthcare Staff Needed by 2030 as S’pore Ages”, The Straits Times, October 5, 2022.
15. Anju Mary Paul, Jiang Haolie, and Cynthia Chen, “If Caring Begins at Home, Who Cares for the Carers? Introducing the Global Care Policy Index”, Global Policy, 13(5), 640-655, 2022.
