The present study was part of a detailed study of almost 550 health workers in nine Pacific island states and, to a lesser extent, in two key destinations: Sydney and Auckland. This chapter focuses on the three largest island states that are key countries of origin (Tonga, Samoa and Fiji), and on the small sample of the health workers who were return migrants. Overall, 64 of the sample were return migrants (see Table 10–1). More than two-thirds of the sample were nurses, about 95 per cent of the nurses were women, and about two-thirds of the doctors were men, all a reflection of the structure of Pacific health sectors.

Early migration of skilled health workers from the Pacific was primarily related to quality of life issues related to the employment context (poor working conditions, inadequate facilities, limited opportunities for research or career development); income (particular professional salary structures, costs of living) and a variety of social factors (educational opportunities for children, morale). In this century, wages and salaries were ubiquitously seen as inadequate. Two-thirds of all nurses and almost half (46 per cent) of all doctors are primarily motivated to migrate for income reasons, a conclusion that is common across countries and across migrant groups (Connell 2004). The specific significance of income is a function of income differentials between Pacific island states and metropolitan states; thus, Tongans were more likely to migrate than Fijians or Samoans because of greater wage differentials between home and international destinations (Brown and Connell 2004). Doctors are almost twice as likely to migrate as nurses, partly because wage differentials are greater but also because men tend to be the decision makers and most nurses are women. Migration occurs in an extended family context.

Economic and political problems in parts of the region have contributed to emigration, exacerbated by economic restructuring, reductions in the size of the public service and deterioration in local working conditions. Work can be difficult and challenging. As one Fijian doctor said:

Table 10–1: Returned Health Workers in Fiji, Samoa and Tonga

Difficult conditions were also a key factor in influencing migration. Some health workers resented long hours of overtime, double shifts, working on the ‘graveyard’ shift or on weekends, for which income is not always properly supplemented. This was particularly so in remote places where few staff are available, hence overtime hours can be long. Like the patients, health workers disliked overcrowding, long queues, lack of supplies and inadequate facilities, and the fact they could not do their job effectively, and repeatedly pointed to problems with inadequate technology, favouritism, over-long working hours, lack of support and respect. In most workplaces, it is normal for some expectations not to be met, especially where workplaces are small (so that chances of promotion are relatively few), but there was abundant evidence of lack of ‘good housekeeping’ and management that supports skilled workers in inevitably challenging situations.

Some of the strongest influences on migration, however, have little to do with employment, or specifically the structure of employment in the country of origin, but much to do with attempts to improve the long term welfare and status of families. In each of the countries many people entered the health professions less out of altruism, or a particular interest in medicine, than through recognition that this might be a means to maximise or at least improve family incomes and welfare. Parents have encouraged their children to enter the profession for the same reason and increasingly so as familiarity with overseas circumstances increases. Employment in the health system thus enables migration as much as being an instigator of it.

Skilled migrants make a substantial contribution to the economic wellbeing of those who remain at home, even compared with those unskilled migrants who profess the certainty of return migration. Remittances, notably in the case of Polynesian nurses, were sustained at high levels, and thus contributed substantially to the welfare of kin in the home country (Connell and Brown 2004). The creation of that income informs many family migration decisions and the use of the money within the home communities to benefit the extended family means that there is always some possibility of return migration.