Gender-Restricted Emigration and Pandemic Repercussions: The Case of Nurse Emigration from India to The Gulf Countries During COVID-19

Introduction

Introduction

The consequences of the global coronavirus disease 2019 (COVID-19) pandemic on the international migration and mobility of workers have been profound. Border closures, quarantine and stay-at-home measures, and the downturn in international travel have all caused disruption to labour migration flows and increased immobility (Martin and Bergmann 2020). For India, this poses a significant concern when we consider the level of it’s internal migration, international migrant remittances, the rate of emigration for India’s workers (skilled and less skilled), and the increasing engagement of India’s youth population in international study (Rajan, et al 2020; Rajan 2020a, 2020b). Healthcare migrants have remained in demand during the pandemic as essential workers were needed to address the surge capacity in the Organisation for Economic Co-operation and Development (OECD) country health systems during the pandemic (Scarpetta, et al 2020). India is one of the world’s leading sources of migrant healthcare workers (Walton-Roberts 2020; Walton-Roberts and Rajan 2020a). How has the pandemic affected India’s role as a global provider of medical workers, particularly nurses? To address this question, we focus on some of the most significant nurse migration markets for India—those in the Gulf Cooperation Council Countries, which have been subject to Emigration Check Required (ECR) regulations since 2015. We describe the regulatory control of this migratory flow prior to and during the pandemic and offer some thoughts about the future of this labour mobility and India’s governance role.

In India, a number of factors structure the recruitment of workers for overseas employment. Of these, three centrally important ones are the type of passport, destination and gender, and occupation. In terms of passports, India uses two distinct types, one is ECR[1] and second Emigration Check Not Required (ECNR)[2]. These operate as a proxy for migrant destination, gender, and occupation (Kumar and Rajan 2014; Rajan, et al 2011). Together these determine the channels through which legal international migration can be routed from India, how this mobility is measured and monitored, and options for government regulation. In 2018, the Ministry of External Affairs (MEA) proposed to issue an orange-coloured passport for ECR passport holders to reduce the hassles for obtaining emigration clearance to work in any of the 18 ECR countries[3]. This move stoked debates on the efficacy and need for ECR/ECNR distinction in passports. The government’s decision to make this distinction more obvious was widely regarded as blatant discrimination toward the less-educated migrants. In light of criticism from different stakeholders, the government abandoned the orange passport proposal. Additionally, at the end of 2018, the MEA issued a notice for the compulsory registration of both ECR and ECNR passport holders moving to any of the 18 ECR countries for employment. However, very soon, the mandatory registration returned to voluntary registration. The statutory provisions and institutional mechanisms to regulate and arguably safeguard Indians emigrating for work to the ECR countries through passport control not only obstruct the process of emigration but also dilute policy responses focused on the welfare of emigrants. Linked to these examples of passport-related regulation of international migration, the existing eMigrate system initiated by the MEA to automate the emigration process is important to understand. Under the e-governance programme, this system attempts to make emigration a simpler, transparent, orderly, and humane process. Further, through the eMigrate portal, the entire process of emigration check is digitised, creating an online platform for workers, recruiting agents, and employers to increase transparency.[4] 

The other two factors (gender and occupation) have also been the subject of extensive discussion and debate related to international legal migration from India. Compared with potential male international migrants, the overseas migration of female migrants is restricted by imposing age slabs and occupation-specific migration controls when the destination is one of the ECR countries. In the case of nurses (unlike domestic workers), there is no age bar for emigration to ECR countries for employment (Ministry of Overseas Indian Affairs 2015b). There are, however, important occupation-based restrictions. In the following section, we first focus on nurses’ emigration from India to ECR countries, then consider nurses inclusion in the purview of ECR category and finally, how gender-discriminatory government regulations prompted Indian nurses to migrate irregularly to Gulf countries.

Nurse Migration from India

Due to a variety of reasons, not least, what is considered the “feminised nature” of the nursing sector and the devaluation of this labour (Bourgeault, et al 2021), the number of men that migrate to the Gulf countries for nursing employment is staggeringly low compared to that of women (see Table 1). The nursing profession in India lacks adequate recognition and professional status, with nurses often overworked, underpaid, and undervalued. The migration opportunities available to nurses have elevated the social status accorded to them in India, especially among women in south Indian communities (Gill 2011). With dreams of living a more financially independent and stable life, women undertake this journey in multitudes. Certain states dominate the production and deployment of nurses, especially in the Southern region of India owing to their history of investment in nurse training (Nair and Rajan 2017). This is clearly shown in figures from 2018 when 6,085 nurses migrated from Kerala, the hotspot of such migration in the country, accounting for approximately 85 percent of ECR-recorded nurse emigrant flows in 2018 (see Table 2).

Table 1: Gender-wise data on Indian nurses that migrated through the eMigrate system

 May 2015–November 2018

Note: * denotes incomplete data.

 

Table 2: State-wise emigration of nurses under ECR (May 2015August 2021)

Note: Data sourced through the Right to Information Act in 2018 and eMigrate in 2021.

* denotes incomplete data.

By far, Saudi Arabia receives the biggest chunk of these migrant nurses with 5,677 and 8,950 migrant Indian nurses arriving in 2018 and 2019, respectively, while the other Gulf countries experienced a comparatively low influx of migrant nurses (see Table 3). As newer opportunities open up for emigrant nurses abroad, they continue to navigate unfair scenarios, migrating with the goal to secure financial security and social stability, which are still largely unavailable to them in India. In the absence of official data collected before 2015, it is challenging to understand the recent trend of nurse emigration from India, that is, the extent to which the inclusion of nurses in the purview of ECR category and pandemic-related migration restrictions has affected nurse emigration rates and patterns from India to the Gulf countries.

 

Table 3: Country-wise Granted Emigration Clearance for Indian Nurses (May 2015August 2021)

Note: Data sourced through the Right to Information Act in 2018 and eMigrate in 2021.

* denotes incomplete data.

Emigration Clearance for Nurses and Its Implications

During 2015, in light of the ongoing exploitation faced by Indian nurses going abroad for employment, the Indian government decided that the emigration of nurses for overseas employment in the 18 ECR countries would now require emigration clearance from the Protector of Emigrants (PoE) offices. Initially, the recruitment of nurses for overseas employment was allowed only through limited state-run recruiting agencies (RAs) such as the Non-resident Keralite’s Affairs (NORKA) Roots and the Overseas Development and Employment Promotion Consultants (ODEPC), Kerala. Later, this ordinance was extended to other state-run recruiting agencies operating in Tamil Nadu, Andhra Pradesh, Telangana, and Uttar Pradesh (Ministry of External Affairs 2016a). In certain cases, select private RAs are allowed to recruit nurses for ECR countries subject to the issue of country-specific order from the Ministry of External Affairs (Ministry of External Affairs 2016b; Ministry of Overseas Indian Affairs 2015a).

The government justified its decision to restrict private recruitment by referencing the occurrence of large-scale malpractices in nurse recruitment for employment to ECR countries[5]. However, it remains possible to bypass the emigration clearance process using private RAs/sponsors to migrate for employment through irregular channels via transit countries or under different visa categories (Heller 2019). The use of irregular channels and intermediaries has resulted in major incidents linked to the recruitment of nurses to the ECR countries since the establishment of the emigration clearance process. In the first instance, two batches of nurses—600 and another 58 nurses were found to have emigrated irregularly to Kuwait via Dubai. They were later stranded without pay and the issue is yet to be resolved (MEA 2019). Second, in 2018, the MEA issued an advisory noting that nursing graduates from India were going to the Gulf for employment on tourist visas and then converting the same into employment visa with the help of RAs/sponsors to evade emigration clearance at PoE (MEA 2018) [6]. These incidents suggest the introduction of emigration clearance for nurses is actually hindering the emigration process instead of facilitating it and is seen as a roadblock that nurses and agents seek to bypass.

Another major barrier nurses face during the emigration process is the economic cost of emigration, that is, service charges collected by both state governmental agencies and private RAs from the nurses to meet recruitment expenses. While initial government orders from the erstwhile Ministry of Overseas Indian Affairs stated that state-run agencies were barred from charging any fees for the recruitment of nurses (Ministry of Overseas Indian Affairs 2015c); this was later revised to allow the collection of a nominal service fee subject to a maximum threshold of Rs. 20,000 as permitted under Rule 25 of the Emigration Rules, 1983 (Ministry of Overseas Indian Affairs 2016). In November 2018, we interacted with nurses at a pre-departure orientation training (PDOT) centre in Delhi. Respondents in our study reported paying higher service fees across the board, whether recruited through public state agencies or private recruitment agencies. In Table 4, we present the data collected from 11 nurses migrating to Saudi Arabia for employment. When asked about the cost incurred for their overseas work, the nurses who migrated through private registered RAs were found to have incurred the highest costs. Table 4 shows the amounts paid by the nurses to RAs, excluding additional charges incurred for documentation by the nurses. This data reveal that nurses are still exploited and financially gouged at the hands of private RAs, despite their inclusion in the eMigrate system for obtaining EC.

One nurse responded to our queries, stating, “I have prepared all the necessary documents and fulfilled other requirements while applying for nurse job in Saudi Arabia.” She continued, “Although I have got this job through government listed RA in Delhi, yet I have paid Rs. 3,00,000 to them in three instalments.” Recounting her experience, another nurse from Tamil Nadu said, “Totally I have paid Rs. 3,00,000 for this job after I have got selected in the interview, I have paid Rs. 1,00,000 to an agent in Tamil Nadu, then after the emigration clearance process, I have paid the balance money to the Delhi registered RA. Also, all the way from Tamil Nadu I have come to Delhi to attend one-day PDOT.” Because of this EC, prospective nurse emigrants can approach only a few authorised private RAs, which results in a monopoly of nurse recruitment from India to ECR countries and creates the conditions for further exploitation. As shown in Table 4, nurses emigrating through state agencies like NORKA are charged significantly less; while one respondent from Kerala going to Saudi Arabia for a nursing job was charged Rs. 3,50,000 through private RAs, others were charged only Rs. 35,000. Furthermore, recent reports indicate that exploitation of migrant nurses by private actors remains endemic to the migration industry, with recruiters turning to new schemes and shortcuts to bypass bureaucratic controls. [7] The scenario depicts that the measures taken by the government to control the conditions and channels of migration and prevent exploitation have been unsuccessful so far, with costs differing widely for the same migration route.

Table 4: Costs incurred by the nurses

Source: Field work, 2018.

*Private RAs have also been permitted to recruit nurses for public and private hospitals in Bahrain, Saudi Arabia, Oman, Jordan, Qatar, etc., through issue of “Country Specific Order” subject to the acceptance of additional terms and conditions stipulated by the MEA (2016b).

A few factors of note here include, first, the process of applying for a nursing job in a foreign country is complex. Initially, nurses have to face an interview or direct selection by curriculum vitae (CV). They then have to undertake the prometric examination, undergo dataflow credential verification procedures, and finally, EC. Alongside all other review and screening procedures, it is unfair to subject nurses to the same stringent procedures applicable to ECR passport holders intending to migrate to ECR countries. Second, our fieldwork revealed that frequently pre-departure orientation training (PDOT) sessions are delivered in an ad-hoc manner to mixed groups of migrants. Holding combined PDOT for nurses with male migrants intending to secure semi-skilled, low-skilled, and unskilled occupations in ECR countries is incoherent and pointless. Unlike India, the Philippines and Sri Lanka hold separate, targeted, sector-specific, and destination-specific PDOT for skilled migrants like nurses (Ali 2005). The lumping together of emigration clearance migrant groups’ orientation shows how Indian government agencies fail to recognise the distinct needs of different migrant groups. This accentuates the needless and bureaucratic demands placed on nurses through processes such as the emigration clearance that are costly in time and money but do not yield effective training and protection for emigrating nurses. It also raises the question of why India is not placing greater emphasis on this skilled and in-demand group of workers who are at the forefront of healthcare delivery in India and elsewhere. In place of deliberate efforts to develop and mobilise nursing labour through budgetary allocations for training and capacity-building, current efforts simply increase gaps and create bottlenecks that further disempower nurses.

Regarding data on Indian nurses working abroad, unfortunately, the MEA does not maintain a database on Indian nurses working in different countries aside from ECR countries. After nurses came under the purview of ECR category, data on nurses in ECR countries who emigrated after obtaining emigration clearance are now gathered. This regulatory approach has, however, relegated nurses to the ECR category, despite the skills possessed by those who are ECNR passport holders. While this process emerged as a response to unlawful practices of some fraudulent private RAs, it places the burden and responsibility on individual nurse emigrants. Illogically, instead of streamlining and regulating fraudulent private RAs, the government pointlessly brought the skilled migrant category (nurses) under the ECR category and imposed the emigration clearance process upon them. Despite these supposed safeguards, based on the data in Table 4 regarding the vastly different fees charged, exploitation is still evident, even by authorised RAs. Additionally, it has been reported that unregistered agents continue to operate and facilitate the trafficking of Indian nurses to Gulf countries where they are made to work as house nurses under the domestic worker visa (Heller 2019) or travel through transit countries and land borders to evade the process of emigration clearance.

The Effects of the COVID-19 Pandemic on Migrant Nurses

Nurses globally have faced mass trauma because of the demands placed upon them by the pandemic, and this has intensified pre-existing nursing labour shortages (International Council of Nurses 2021). Analysis of the international supply of nurses and the consequence of COVID-19 suggest that the demand for international migrants will remain in this area because key destination countries have not secured self-sufficiency in training and retention. Moreover, countries such as the Philippines and India, which are the major suppliers of nurse labour globally, are facing potentially significant “emerging shortages” (International Council of Nurses 2021). While OECD countries and the Gulf region have greatly benefitted from the presence and participation of Indian-trained nurses, particularly during the COVID-19 pandemic, the current moment has laid bare India’s acute shortage of trained healthcare workers (Karan, et al 2021). With 1.7 nurses per 1,000 population according to the Ministry of Health and Family Welfare statistics, 2018 [8], India falls short of the current World Health Organization (WHO) recommended threshold of 3 nurses per 1,000 population and requires 4.3 million more nurses by 2024 to meet their norms (WHO 2018). To address the high patient burden and uneven distribution of health workers in medical settings across India, the government actively recruited more nursing staff and graduates during the COVID-19 pandemic. However, these new hires were inducted on contractual basis and required to work long hours with insufficient Personal Protective Equipment supplies and support (IIPS 2020). Some have been subjected to public harassment and rejection linked to stigma associated with the COVID-19 virus, leading to mass resignations in some cases (Bhattacharya, et al 2020). Low wages and insecure working conditions have amplified the stressors of the pandemic on the nursing sector, prompting thousands more to migrate overseas in search of better working conditions and recognition. [9]

Comprehending the full impact of these international flows will require improved data collection and addressing the situation demands international cooperation and greater adherence to the WHO Global Code of Practice on the International Recruitment of Health Personnel (Buchan and Catton 2020). The outbreak of COVID-19 has had a multiplier effect on the global demand for Indian nurses and continues to reach record high as countries implement vaccination drives and strengthen their healthcare systems for possible future waves or pandemics. Countries such as the United Kingdom (UK), Ireland, Germany, Malta, Netherlands, and Belgium have indicated interest in facilitating increased nurse migration from India, while the Gulf region alone has more than doubled its demand for this critical workforce.[10] Despite border closures and entry restrictions wrought by the pandemic, exceptions have been made for the reception and integration of migrant health workers. The United Arab Emirates granted special approvals to healthcare employees and recruits impacted by travel bans from India.[11]

The Kerala government-run ODEPC experienced over a sixfold increase in monthly nurse recruitments in the early part of 2021. Even as India’s health system battles the ongoing public health crisis, it has deployed rapid response medical teams and healthcare worker contingents to Gulf region in a show of support and solidarity.[12] [13] Countries that were already reliant on migrant health workers prior to the pandemic have taken efforts to mobilise migrant health workers in their COVID-19 response (Organisation for Economic Co-operation and Development 2020). This includes initiatives to ease their entry, accelerate recognition of their professional qualifications, and enable their labour market participation, even offering additional pay and perks (Foley and Piper 2020). Reduced visa charges and one-year visa extensions granted to overseas health workers in the UK are widely reported as having benefited Indian doctors and nurses. The United States (US), Canada, and other OECD countries have announced similar policy moves and exemptions for migrant healthcare workers (Kumar 2021). As long as overseas public health demands combined with demographic challenges and wage and work conditions remain a draw for Indian nurses straddling a weak domestic system and restrictive regulations, their movement will continue by any means necessary.

Conclusions

In summary, to address the exploitations faced by nurses during recruitment for overseas employment, the government regulated nurse migration in the Gulf corridors rather than the recruiters. This resulted in recruiters and emigrants finding other channels/routes to evade the emigration clearance, allowing private RAs to charge high fees for nurse emigration, both of which are yet to be systematically addressed. For nurses in our study, fees paid to private RAs are a huge financial cost. Although, the state-run agencies are allowed to collect service charges under Rule 25 of the Emigration Rules, 1983, nurses reported paying substantially more for services rendered through private RAs and incurring high recruitment-related costs to access state agencies. Therefore, it is our opinion that an active campaign should be initiated to rollback onerous processes and to stop both irregular recruitment and excessive charges. Bringing nurses (skilled migrants) under the purview of the ECR category to protect them is not an appropriate or adequate measure to achieve the safety and protection of Indian nurses emigrating to the Gulf countries for employment.

A coherent approach to addressing existing and emerging challenges in nurse migration from India is long overdue. Current recruitment restrictions remain out of step with commitments made by the Ministry of Skill Development and Entrepreneurship to skill and supply 3,00,000 healthcare workers to the US, the UK, Germany, Australia, Japan, Sweden, and Singapore by 2022 (Kumar 2021). As India explores opportunities for bilateral agreements on health personnel supply, every effort must be made to align with and integrate the principles contained in key International Labour Organization and International Organisation of Migration instruments on migration and recruitment.[14]

Nursing labour will continue to be in global demand and India should be investing in improving the quality and status of nursing in order to strengthen local health systems and maximise on the migration opportunities this provides for nurses and sending and receiving countries (Karan, et al 2021). Recent moves to streamline the “export of talent” from sectors such as healthcare in India signal a departure from current constraints on movement.[15] As the National Commission on Macroeconomics and Health report observed, “with the large number of opportunities opening up for employment in foreign countries, particularly for nurses, it would be to India’s advantage to focus on expanding the number of colleges and nursing schools alongside efforts to ensure good quality to make them employable” (Government of India 2005: 63). Downgrading nursing to ECR is not the way to address this quality and upskilling issue. Rather, scaling up nursing programmes and streamlining pre-departure protocols need priority attention. Finally, to manage nurse migration, the government should examine other promising practices and initiatives (for example, the Philippines) and consider how management of nurse migration can build on international norms and conventions, including aspects of the Sustainable Development Goals  (Walton-Roberts, et al 2017; Thompson and Walton-Roberts 2018).

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