A significant number of health workers have returned to the Pacific island states, but not all of them return to work in the health sector. Indeed the majority probably do not (but because the survey data come from workers currently in the health sector, we cannot define this proportion). About one-third of the existing health workforce were returnees, though most of these had been overseas to train and were bonded to return, rather than having come back, usually later in life, for different reasons. In terms of reasons for return (see Tables 10–2 and 10–3), the substantial numbers listed as ‘other’ represent those who were bonded to return and thus had no real choice in the matter, while ‘home country’ in some cases was simply a more elegant way of indicating this bonding. More than half of the doctors and at least one-third of the nurses who had returned were bonded, and usually did so before significant overseas work experience. Again this indicates the small residual numbers who had specifically chosen to return. Two-thirds of the returnees were women, but that simply reflects the gendered composition of the nursing workforce. Among those who were not bonded, the returnees were not particularly young, but had largely returned in mid-career, suggesting their presumed ability to contribute to the workforce.

Beyond bonding, social reasons influenced return, for both doctors and nurses (see Tables 10–2 and 10–3), including the rather nebulous ‘home country’, but being with friends and relatives and accompanying a spouse home were highly significant. For a considerable proportion (even excluding those who were bonded), return was perceived as something of a duty rather than entirely an act of free will. Conversely, just one Samoan nurse claimed to have returned for ‘higher wages and better jobs’. In other words, employment in the health sector, or good wages, were not incentives to return.

Table 10–2: Reasons for Return—by Country

¹ as a percentage of number of returned nurses/doctors of each country

² as a percentage of total returned respondents of each country

Table 10–3: Reasons for Return—Overall

¹ as a percentage of number of nurses/doctors who had returned to their countries

Migrants tended to return at key moments in the life cycle—after training for example, or when children had graduated—but at least as often when their parents had particular need of them. Thus many returned not necessarily at times of their own choosing or of their own volition, but in response to family needs or crises, influenced by the circumstances of others rather than themselves or their nuclear families. The repeated mobility of Tevai, a Cook Islands nurse, almost entirely in response to extended family needs (Hooker and Varcoe 1999, 94), is a typical if complex example of such a migration scenario, where Tevai and her family repeatedly balanced opportunities for income generation in Australia to provide economic support, with the need to be close to family in the Pacific to provide social support. Social obligations underpin this and other migration histories.

Nonetheless, those who had returned to work in the health sector earned significantly more than those who had never migrated and this was especially true for Samoa and Tonga (see Table10–5). Similarly, returnees in Tonga and Samoa, more than in Fiji, also generally received incomes that were greater than other households (Brown and Connell 2004). Correspondingly, the numbers and proportions of those who returned to Samoa and Tonga were greater. Nevertheless, these relatively high incomes are low compared with incomes that might have been, or were, obtained overseas and hence do not explain return.

Migration itself was less likely to occur where health workers owned a house or business in their home country; in other words they are well-established economically (Brown and Connell 2004; cf. Brown 1997). Likewise, returning health workers are particularly likely to establish a business on their return, having accumulated enough savings to make this possible, a pattern that occurs more widely among all returnees (Brown and Connell 1993; Maron and Connell 2008). There is, therefore, a key economic rationale for return migration outside the health sector, enabling a degree of individualism, independence and autonomy from that sector. As a result, many return migrants to the health sector become part of multiple income households.

Alongside individual choice, bureaucratic and structural obstacles may also hinder return to the health sector. Such obstacles include starting again at the bottom of the system (rather than gaining promotion by dint of new skills and experience acquired overseas) that cancel out any status or professional recognition gained from migration. Accrued benefits may also have disappeared and, even then, there may be jealousy from co-workers who have not had overseas experience (and may see returnees as seeking to lord it over them). Moreover, unless there have been changes to the health system during the absence of the migrants, the old flaws and failings are reencountered and perhaps made worse by overseas experiences had in invariably better functioning systems.

Predictably, returnees were often frustrated with the health sector, which usually compared poorly with those they had returned from and/or been trained in. Those who had been forced to start again at the bottom of the employment hierarchy were particularly frustrated. Most frustrations and complaints related to work conditions and lack of recognition of skills and knowledge, which sometimes amounted to at least perceptions of blocked promotion, though many returnees expressed satisfaction at working for the government with the prestige, reliability and stability that it provides. Others were less enthusiastic: ‘I had expectations of promotion and a salary rise’; ‘I am better qualified than anybody in the Divisional level. Since my return from Australia, I haven’t been promoted. In addition what I am doing is nothing to do with my specialised area of epidemiology’; ‘I am burdened with responsibility’; ‘long hours’; ‘decisions made from higher levels of the hierarchy and no say from lower levels’; ‘I want to upgrade my knowledge but it is too difficult’; ‘this is my first year as a junior registrar and I have been appointed to a post with a lot of responsibilities and been deprived of a lot of sleep: overworked and underpaid’; and ‘overwork: surely no hospital in the world can employ someone over 32 hours?’ More generally ‘not having normal hours’ and ‘little separation of work and leisure time; we are always expected to be available’, distinguished employment in the health system from that in other areas. Such responses characterised the most obvious dissatisfactions though, with certain exceptions, many similar problems might also have been experienced overseas.

Many complaints were directed at a seemingly uncomprehending and uninterested bureaucracy. An Indo-Fijian doctor who had returned to a provincial posting found it not only ‘boring’ but also,

He could not wait to leave, either to Suva or overseas. Somewhat differently, another doctor elsewhere spoke of ‘male chauvinism within the Ministry of Health’, and others reflected more broadly on the ‘failure of the…government to prioritise health care’ or ‘the communication gap between the Ministry and the workers’.

Other returnees stressed nepotism and favouritism in island health care systems, particular problems in small health systems in societies where cultures centred on kinship remain important. Stability in a small workforce where there is limited turnover (or what is perceived to be limited turnover) may discourage innovation and change; younger staff found some frustration when trying to implement change and new ideas, especially where it works elsewhere. These kind of ‘crab antics’, that discourage innovation and ideas, are not unusual in many workplaces in Pacific island states. One former nurse commented: ‘nurses have no autonomy’. Others perceived a lack of respect and support for junior staff, entrenched in the generation gap. In many respects this is universal: in all workplaces some expectations will not be met, though there seemed to be no work climate where new innovations were valued.

Others were frustrated by a lack of adequate technology and there was a constant refrain about problems such as ‘lack of equipment’; ‘not enough money for medicines’; ‘staff shortages’ and even simply ‘other nurses’, all of which affected morale and were essentially related to insufficient investment. Some of the concerns of the returnees were not merely about the factors that made it difficult to do the effective and rewarding job that they sought to do for themselves and their patients, but went beyond that to issues affecting the whole practice of medical care. Many problems are generic to health systems the world over, notably inadequate equipment and medicines, night shifts and problem patients but ultimately, the greatest concerns were about what one nurse perceived as ‘failures in the job’, such as ‘seeing loved ones die’ or ‘when one is unsuccessful in helping a patient to live’. By contrast, when patients survived against the odds there was the greatest satisfaction.

Somewhat less frequently, qualifications and skills are acquired overseas that are simply too specialised, notably in outer islands, small towns and in very small states such as Niue (Connell 2007, 2009), where a more general multiskilling characterises smaller workforces. Some careers and expatriate social lives are more demanding and fascinating and simply do not exist at home for ‘high fliers’. Return would demand too many social and economic sacrifices and unacceptably constrained opportunities. As one returnee, who had moved out of the health sector before being attracted back, said:

Matching local needs and overseas skills is never easy.

Indo-Fijians tended to be the most critical of the circumstances that they found themselves in upon return, perhaps with reason; as did those who had returned to rural and regional positions, but there were no distinct national variations in satisfaction or otherwise.

While there were inevitable frustrations about work issues, many respondents were more positive and optimistic about the contributions that they had been able to make and more generally about the benefits for themselves and their families of returning home.

Consequently, despite frustrations with bureaucracies and facilities, there was also recognition that the health sector had some advantages in itself: ‘the salary is higher than other jobs in Tonga, I gained prestige through my return and the work is appreciated by the people’. And ‘I’ve worked in Melbourne but it seems that you are doing it for the money. Here you don’t get much money but you feel that you’re really helping people’. Inevitably, considerable satisfaction was attached to the ability to contribute to a more successful workforce: ‘saving two lives of a mother and baby…and working as a team with other nursing, medical and non-medical staff’; ‘looking after people and planning for the health of the community’. Sometimes that was directly attributed to migration, through the ‘use of overseas knowledge and skills to benefit Tonga’ but usually satisfaction was simply implicit in doing a good job. For one nurse, this amounted to ‘the pleasure of living with my family, low expenses, working with my own people, and being able to contribute to the government, the country and the people’. It is perhaps true that, rather more than in almost any other sphere, returned health workers are able to believe, make and sustain such claims.

Yet fitting in again posed some problems. While returnees were usually able to readjust to island lifestyles the transition was not always easy: ‘I had culture shock coming back into Tongan culture, but in the end I was glad to be back’. Challenges also involved the attitudes of patients where these did not fit ‘western’ medicine: ‘frustration with elderly patients who rely on traditional Tongan medicine rather than western medicine’. Although ‘my parents are here, it is more comfortable living in Tonga and the job is more flexible’, that sometimes necessary flexibility was a problem for those who had acquired specialisations and disliked having to become generalists. Here, as in other contexts, some were able to readjust and reintegrate, others found it more frustrating and resented being able to use only a fraction of what they had learned and practiced overseas. Those who had returned for the sake of others were most challenged by return and envisaged future emigration.

Table 10–4: Intended Future Migration of Return Migrants—by Country

¹ as a percentage of number of nurses/doctors (who had returned) of each country

² as a percentage of total respondents who intend to migrate of each country; for reasons of space categories that had no responses have been omitted.

The real pleasure of return lay in the social context. This usually had little to do with the workplace but was about a ‘more comfortable pace of life’ among family and friends. Many of those who had moved back emphasised the climate, safety or the more relaxed pace of life, or simply the familiarity of the home country, indicating again how crucial social, political and economic stability is to return migration.

While return migration was for social reasons, reemployment in the health sector may even have been reluctant and others may have dropped out of the workforce, there is no clear evidence that those who had returned were ‘failures’ (though the methodology precludes their being recognised). Rather, it tended to suggest that returnees have contributed to national development and that even if some felt that they had in some sense ‘failed’, many had made an effort and battled against stubborn bureaucracies and difficult conditions.

Of the returnees some 25 (29 per cent), about one-in-three nurses and one-in-two doctors (see Table 10–4 above) wanted to migrate again ‘soon’. Although intent is different from action, at the very least some degree of ambivalence followed return migration, especially when that return was stimulated by the needs of others. Such a new phase of migration would be motivated by desire for better education and new experiences for the individuals and for their children, underpinned by higher wages and a better job (see Table 10–5). Poorly paid nurses tended to seek to move for higher wages and doctors for new education and training, but overall an economic rationale was significant. Even some of those who were aware that they were doing a valuable job and enjoyed it, found it difficult to balance this with their knowledge of ‘higher wages and a better quality of life overseas’ that presented a constant lure and temptation. Nonetheless, some strenuously denied any intention to go: ‘If the worse comes to the worst I’d leave, but otherwise I’d rather stay here’ and ‘even in the worst situation I’d feel obliged to stay here’. Yet in the present climate of overseas recruitment and substantial demand for skilled workers, usually only older workers did not see migration, however improbable, as both temptation and possibility.

Table 10–5: Intended Future Migration of Return Migrants

¹ as a percentage of total nurses/doctors who had returned to their countries

² as a percentage of nurses/doctors who intend to migrate future

Those who intended to remain wished to stay, by contrast, because it was home and where their relatives and friends lived (see Table 10–6). In a wider sample of all health workers in Tonga, Samoa and Fiji, among those who had never gone overseas, income was even less evident as a reason for staying. This was especially so for nurses, whereas almost half of the doctors who had chosen not to migrate indicated that income was a factor in their staying, despite the fact that they earned about one-third of what they might have done overseas (Table 10–7). Alongside family ties, owning a house in the home country is a significant brake on leaving, whereas being trained overseas is a major influence on migration (Brown and Connell 2004). Returning and staying tend to be social phenomena, while leaving is an economic one; mobility is a constantly unfinished story.

Table 10–6: Reasons for Remaining—by Country

¹ as a percentage of number of returned nurses/doctors of the country

² categories with no responses have been omitted

³ as a percentage of total respondents who intend to remain in the country

Table 10–7: Comparison of Annual Income between Return Migrants and Never-Migrated Health Workers*

* All income data are in Australian dollars