Insights from India’s Nurse Migration: Lessons for Bangladesh
It has now been almost half a century since Indian nurses began migrating abroad, long enough to understand the difficulties and benefits they have encountered in their professional and personal journey. I have studied their migration since the 2000s.
Nearly half of the world's international migrants (48.1%) are women. Most of the academic literature thus far addresses the case of unskilled women, particularly female domestic workers, and mainly highlights the different types of exploitation they are subject to. In most countries of origin, the migration of women is still seen as dangerous for them, and policies have tended to restrict their ability to go abroad.
I, certainly, don't want to minimize the hardship many women may be suffering from when working in another country, and particularly in the Gulf countries, but I think it is necessary to make a clear distinction between uneducated, often illiterate and very poor women and women who are educated, have skills and are a lot more knowledgeable about what to expect and about their rights. Migrant nurses belong to this latter category. More generally, I will add that the rather systematic victimization of female migrants (the almost only aspect which appears in the global media for instance) is indeed often tainted with patriarchal stereotypes which consider women as weak, minor and unable to deal with life when far from the family environment.
The first Indian nurses who left for the Gulf countries by the end of the 70's had not planned to go abroad. At that time, those women obviously did not really know what to expect, apart from a lot better salary than in Indian hospitals. Almost all of them were women from Kerala in their late 30's or 40's, married and mothers. As brave pioneers, they took the risk to go although, in their own society, this choice was at that time strongly looked upon. Their morality was particularly questioned. The reality was, naturally, very different. Keralese nurses had a quasi-monastic life: their day or night in their hospital ward and, when off duty, they were living in hostels in the hospitals' compounds and were never going out of it. Their life was a difficult one, yet, as many explained to me, they were proud to be able to significantly help their family with the remittances they were sending. This power of so much contributing to a family's prosperity soon became common knowledge in Kerala and the prejudices against migrant nurses slowly faded.
The next generation of Indian nurses, contrarily to their elders, had planned to go abroad from the beginning of their nursing studies. By that time, the South Asian diaspora had also developed a lot in the Gulf, making it possible to have a social life in these countries where relations between different communities are not so frequent. So, apart from their duty time, Indian nurses started to get out of the hospital compounds: going to religious services, shopping, visiting friends who had settled in town and so on. More and more nurses had managed to have their husband joining them and were living in their own apartment. Today nurses, in their vast majority, describe their life in the Gulf as an interesting one, in a cosmopolitan environment they appreciate, but also in a professional environment which is, according to them, a lot more satisfying than the one they could expect in India.
This better professional background has another consequence: the experience nurses get in the Gulf's hospitals which often offer a high technicity, as well as the level of English fluency they get there, allows them to more easily apply to positions in Western countries. Many nurses I met in the Gulf are nowadays living in UK, Ireland, USA, Australia, etc. Over time, many had also significantly progressed professionally: from ward nurses at the beginning, they got positions as highly specialized nurses, matrons or supervisors, thanks to trainings they were offered by the hospitals they were working in and thus having salaries increasing accordingly.
In the course of my long research, I have, of course, met some women whose migration' story was not positive. It could be a few cases of bad contracts, bad working conditions in small private institutions or an inability to adjust to a foreign environment which is not such an easy thing, but, among the hundreds of migrant nurses I spent time with, these cases are clearly a minority. The vast majority of them acknowledge the benefits they got from their move abroad and, very importantly, all of them underline the changes in their life as women.
The fact of becoming, most often, the best bread earner of the family obviously gives them a power that women with low or no wages at all can't have. The importance of financial independence has indeed since a long time been recognized by all scholars as a key factor leading to more female autonomy. This is exactly what migrant nurses experience: they explain how they now have an important say in the family decisions, how they are able to have a renewed relation with their husband in a way which would have been difficult by staying at home. At last, many of them enjoy living in a more cosmopolitan atmosphere: the diasporic environment, although it is largely respecting social traditions, however offers them more freedom and opportunities of personal development.
To sum up, migrant nurses have certainly to face many challenges: leaving one's dear ones behind, adapting to a new environment, speaking a new language, working hard in a profession which is very demanding, etc. It cannot be denied that this requires strength and will power and there is much to admire about these women and what they have been able to achieve. Yet, contrarily to so many migrants -male or female- whose migratory trajectory ends up tragically in exploitation, deportation or indebtedness, nurses are in a position to earn from migration, whether it is financially or in term of social or personal status.
Tens of thousands of Indian nurses are nowadays working abroad. This is obviously not the result of individual decisions only. This specific migration has -if not officially, at least practically- been accompanied by the Indian State. The liberalization of nursing education gave way to the opening of numerous private nursing schools in order to train a growing number of candidates. Considering the goal of most of their trainees, the curricula followed by these institutions tended more and more to reach international standards. A full sector developed to provide services for nurses ready to migrate.
There are training centers which helps in language skills (preparing for the IELTS), preparing to diploma needed in order to migrate in Western countries such as the CGFNS (Commission on Graduates of Foreign Nursing Schools) required to work in the USA. Almost all of the women candidates to migration attend such training.
Then, there is a full sector of specialized recruitment agencies that most candidates choose on the recommendation of fellow nurses who previously used them, thus limiting the number of abuses. All of this obviously has a cost for the potential migrant. Yet, according to my interlocutors, if this put a heavy strain on the first years of migration, the return on investment is almost guaranteed once you have got a job abroad. It has to be remarked that the first generation of migrant nurses were in a better position in this regard: no investment was needed for their migration since there were only governmental and, so, free nursing schools and since the recruitment was directly organized in India by the foreign hospitals. The privatization and financialization of the nursing sector -including ways of migration- was therefore a political choice of the Indian government and not at all a fatality.
Now, would it be a good idea that Bangladeshi nurses follow the example of their Indian sisters? And would that be possible? Based on the Indian case, one may assess that, at an individual level as well as from a national point of view (considering the potential remittances), one could certainly consider this as a good option. Nevertheless, to be realistic, at the present time, several factors seem to seriously compromise this possibility.
Having, fortunately, never been ill during my visits to Bangladesh or never having had to visit a sick friend, I never had to visit a Bangladeshi hospital. My information is therefore based on discussions with friends who had experienced such situations, but also with a few medical assistants to whom I could ask precise questions and discuss the topic of potential migration. From what I learned, both the training and the actual duty or the practical experience of nurses in Bangladesh appear to be rather far from what is expected at an international level. This would rather correspond to the level of assistant nurse in the Gulf or in the global North. Then, contrarily to India where all the training is done in English, it is Bangla which is mainly used in the Bangladeshi nursing schools. So, it means a poor curriculum in nursing schools compared to other countries, no language skills and, then, a lower level of technical practice: all of this is clearly not arguing in favor of possible recruitment of Bangladeshi nurses by foreign hospitals, at least in the current situation.
On the other hand, Bangladesh has trained tens of thousands of medical assistants who, for many, are sadly unemployed despite their qualifications. It is perhaps in that direction that one may imagine and organize some opportunities of migration. The medical assistants I met (they were young women), described their job as rather well corresponding to a nurse duty in a more international context. What I could check of their training curriculum may also better match international standards. These women, in addition, confirmed to me their willingness and the willingness of many of their fellows, if it were possible, to go abroad for better prospects.
However, two factors -so far- block this option and they are not really resolvable at an individual level. At first, there would be a need for a recognition of an equivalence between the nursing degree (as defined at an international level) and the Bangladeshi medical assistant degree. This can only be discussed at a state level, or at least between the Bangladeshi State and recruiting hospitals abroad. Then, as I could check while discussing with the medical assistant I met, although they had some training in English, their language skills are actually too poor for an international career. If, individually, this could be improved, it may also be needed, if migration of medical professionals was seen as a good option for the country, to organize a good training in this regard to render candidates to migration comfortable and efficient enough in their future career abroad. At last, but not the least, to avoid scams, different sort of abuses or exploitation, it would be safer, at least at the beginning, that the recruitment would be done through State agencies in direct contact with foreign hospitals.
Bangladesh has, at least since the Bangladesh Climate Change Strategy and Action Plan (BCCSAP, 2009), stressed the importance that international migration may have in her future development and adaptation to environmental and economic stresses. She has also regularly remarked that there was a need for a clear improvement in the skill level of her migrants, which in fact is, up to date, the lower among South Asian countries. This need of improving migrant skills serves two purposes: more skilled workers mean more remittances; it also means a lower risk of exploitation, something which is so often the fate of uneducated and unskilled migrants. To organize and facilitate the migration of medical assistants -among whom many are women- as nurses abroad could therefore fit perfectly with this policy and it would certainly meet the aspirations of many of them.
Marie Percot is an Anthropologist at the French National Council for Scientific Research (CNRS). She is currently a Visiting Professor at the International Institute for Migration and Development (IIMAD), Kerala, India. She can be contacted at [email protected]