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In Brief: "We Shall Travel On": Quality of Care, Economic Development, and the International Migration of Long-Term Care Workers

Introduction and Purpose

This In Brief summarizes the findings of the AARP Public Policy Institute Research Report, "We Shall Travel On": Quality of Care, Economic Development, and the International Migration of Long-Term Care Workers. The most intimate care to frail older persons in developed countries is increasingly provided by young women whose native language, race, and culture are different from those they serve. This report examines demographic, social, and political factors driving the increased international migration of long-term care workers to developed countries.

Demographic, Economic and Social Factors Shaping Migration Patterns

Demographic, economic, and social factors driving the international migration of long-term workers to developed countries include:

  • Demographic Trends — The demographic challenge is twofold: 1) growth in the size of older populations, and 2) a diminishing supply of workers to fill long-term care jobs.
  • Skill Levels and Working Conditions — Demand for higher skill nurses and lower skill aides is high, but immigration policies promote only high skill migration.
  • Gender and Race — Migrating women from racial minority groups provide increasing amounts of long-term care in several developed countries.
  • Historical and Geographic Relations — Migrating long-term care workers most often come from former colonies or geographically neighboring countries.

Policy Decisions and the Migration of Long-Term Care Workers

Policy decisions in the following areas also play a major role, intentional and unintentional, in the volume and patterns of international migration to provide long-term care:

  • Long-Term Care Financing Policies — Public policies on long-term care financing affect the demand for various types of international workers.
  • Immigration Policies — Most developed countries have been reluctant to open their doors to more immigration, especially to unskilled workers.
  • Education and Credentialing — Education and credentialing requirements can be a method for limiting the admission of long-term care workers, especially nurses.
  • Worker Recruitment — Selective recruitment, formal and informal, also shapes the migration patterns of long-term care workers, especially among skilled nurses.

Snapshots of Migration in More Developed Countries

The report includes snapshots of specific developed countries receiving the international long-term care workers.

  • Japan — Japan has some of the most pressing demographic needs but still has very restrictive immigration policies.
  • Scandinavian Countries — Sweden and Norway fund a substantial array of long-term care services, with small but growing numbers of foreign-born workers.
  • Italy — Changing roles of women and a modest cash benefit financing system have fueled demand for international home care workers to augment traditional family caregiving.
  • Austria — Cash benefits and a tradition of home care have encouraged the use of international long-term care workers in Austria, mostly from neighboring countries.
  • United Kingdom — The UK is one of the largest importers of professional health care workers in the world, a large percentage of whom work in the long-term care system.
  • United States — The number of foreign-born workers in U.S. long-term care settings has increased substantially over the last 20 years, especially in central cities.

The Migration of Long-Term Care Workers and Implications for Countries of Origin

The economic and professional incentives to migrate often create problems for the health care systems of the source countries in the developing world, including:

  • Skill Loss — Whether migration is a "brain drain" to source countries depends on: 1) health needs; 2) the percentage of workers that migrates; and 3) the patterns of migration.
  • Economic Impact — Remittances are an important source of revenue, but they also come at the expense of the loss of workers who are at the peak of their productive years.
  • Education — Migration has had both positive and negative consequences for the quality of nurse education in developing countries.
  • Gender — Nursing provides job opportunities and liberation to many women who migrate, but exploitation in the host countries is distressingly common as well.
  • Integrating Foreign Long-Term Care Workers — Integrating migrating nurses and aides into the host countries can be a major challenge. Discrimination is reported frequently.

The Migration of Long-Term Care Workers and Implications for Quality of Services

The report concludes with a discussion of policy questions regarding the migration of long-term care workers that must be addressed at the national and international levels.

  • Is immigration the best way to address worker shortages?
  • How can public agencies be sure that international workers are qualified?
  • How can developed countries meet the demand for unskilled workers?
  • How do cultural and linguistic differences affect quality of care?
  • Do migrating workers depress wages and undermine working conditions?
  • What responsibility do developed countries have for the impact of migration on source countries?


  1. Redfoot, Donald L. and Ari N. Houser. PPI Issue Paper #2005-14. October 2005

Written by Donald L. Redfoot, AARP Public Policy Institute
October 2005
©2005 AARP
All rights are reserved and content may be reproduced, downloaded, disseminated, or transferred, for single use, or by nonprofit organizations for educational purposes, if correct attribution is made to AARP.
Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049

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